Malanga et al • Provocative Tests in Spine Examination 199 Pain Physician. 2003;6:199-205, ISSN 1533-3159 Focused Review Provocative Tests in Cervical Spine Examination: Historical Basis and Scientific Analyses Gerard A. Malanga, MD, Phillip Landes, MD, and Scott F. Nadler, DO The majority of the provocative tests described for physical examination of the neck and cervical spine relate to identification of radiculopathy, spinal cord, or brachial plexus pathology. These tests are often performed routinely by many providers with variable methods and interpreted in a variety of ways. Several commonly performed provocative tests include Spurling’s Neck Compression Test, Shoulder Abduction (Relief) Test, Neck Distraction Test, L’hermitte’s Sign, Hoffmann’s Sign and Adson’s Test. This review describes some specialized provocative tests with comprehensive literature review. The goal of this review is to develop standardization in the performance and clinical use of these tests. Each of the tests described in this manuscript apparently originated from the anecdotal observations of experienced, well respected clinicians. However, only few studies have been performed addressing the interexaminer reliability or validity of these tests. The existing literature appears to indicate high specificity, low sensitivity, and good to fair interexaminer reliability for Spurling’s Neck Compression Test, the Neck Distraction Test, and The Shoulder Abduction (Relief) Test when performed as described. For Hoffman’s Sign, the existing literature does not address interexaminer reliability but appears to indicate fair sensitivity and fair to good specific- ity. For L’hermitte’s Sign and Adson’s Test, not even tentative statements can be made with regard to interexaminer reliability, sensitivity, and specificity, based on the existing literature. It is concluded that more research is indicated to understand the clinical utility of all the provocative tests employed in the physical examination of the neck and cervical spine. Keywords: Provocative tests, cervical spine, Spurling’s Neck Compression Test, Shoulder Abduction (Relief) Test, Neck Distraction Test, L’hermitte’s Sign, Hoffmann’s Sign, Adson’s Test, sensitivity, specificity Many฀ specialized฀ provocative฀ tests฀ have฀ been฀ described฀ for฀ physical฀ examination฀of฀the฀neck฀and฀cervical฀spine.฀฀The฀ majority฀ of฀ these฀ relate฀ to฀ identification฀ of฀ radiculopathy,฀ spinal฀ cord฀ pathology,฀ or฀brachial฀plexus฀pathology.฀฀These฀tests฀ are฀ often฀ performed฀ routinely฀ by฀ many฀ providers฀ with฀ variable฀ methods฀ and฀ interpreted฀in฀a฀variety฀of฀ways.฀ The฀purpose฀of฀this฀review฀is฀to฀describe฀ several฀ commonly฀ performed฀ specialized฀ provocative฀ tests฀ used฀ in฀ examination฀of฀the฀neck฀and฀cervical฀spine฀regions.฀฀For฀each฀test,฀the฀origin,฀technique,฀ reliability,฀ validity,฀ and฀ clinical฀ significance฀ are฀ discussed,฀ based฀ on฀ a฀ comprehensive฀ search฀ of฀ the฀ existing฀ literature.฀฀ The฀goal฀is฀to฀develop฀standardization฀in฀ the฀performance฀and฀clinical฀use฀of฀these฀ tests. I. Spurling’s Neck Compression Test Spurling฀and฀Scoville฀first฀described฀ Spurling’s฀ Neck฀ Compression฀ Test,฀ also฀ known฀ as,฀ the฀ Foraminal฀ Compression฀ Test,฀Neck฀Compression฀Test,฀or฀Quadrant฀ Test,฀in฀1944฀as฀“the฀most฀important฀diagnostic฀test฀and฀one฀that฀is฀almost฀pathognomonic฀ of฀ a฀ cervical฀ intraspinal฀ lesion”฀ (1).฀฀Their฀observations฀were฀based฀on฀the฀ presentation฀of฀12฀patients฀with฀“ruptured฀ cervical฀ discs”฀ verified฀ during฀ surgery฀ in฀ 1943฀at฀Walter฀Reed฀Army฀Hospital.฀฀The฀ authors฀ state฀ that฀ during฀ the฀ same฀ period฀ many฀ more฀ of฀ these฀ cases฀ were฀ diagnosed฀ but฀ not฀ verified฀ surgically.฀ ฀ They฀ described฀฀“the฀neck฀compression฀test”฀as฀ follows฀(1).฀฀฀฀฀ “Tilting฀ the฀ head฀ and฀ neck฀ toward฀ the฀ painful฀ side฀ may฀ be฀ sufficient฀ to฀ reproduce฀ the฀ characteristic฀ pain฀ and฀ radicular฀ features฀ of฀ the฀ lesion.฀ ฀ Pressure฀ on฀ the฀ top฀ of฀ the฀ head฀ in฀ this฀ position฀ may฀ greatly฀ intensify฀ the฀symptoms.฀฀Tilting฀the฀head฀away฀ from฀the฀lesion฀usually฀gives฀relief.” Currently฀ the฀ test฀ is฀ described฀ as฀ “performed฀by฀extending฀the฀neck฀and฀rotating฀the฀head฀and฀then฀applying฀downward฀ pressure฀ on฀ the฀ head.฀ ฀ The฀ test฀ is฀ considered฀ positive฀ if฀ pain฀ radiates฀ into฀ the฀ limb฀ ipsilateral฀ to฀ the฀ side฀ at฀ which฀ the฀head฀is฀rotated”฀(2).฀฀Some฀authors฀advocate฀performing฀the฀components฀of฀the฀ test฀in฀a฀staged฀manner฀and฀halting฀with฀ the฀ onset฀ of฀ radicular฀ symptoms,฀ preferably฀reproducing฀the฀patient’s฀presenting฀ symptoms฀(3-5).฀฀Radicular฀symptoms฀are฀ described฀ as฀ pain฀ or฀ paresthesias฀ occurring฀ distant฀ from฀ the฀ neck,฀ in฀ the฀ distribution฀of฀a฀cervical฀spinal฀nerve฀root. Vikari-Juntura฀(6)฀performed฀a฀prospective฀study฀in฀1987฀to฀assess฀the฀interexaminer฀reliability฀of฀common฀tests฀generally฀performed฀in฀the฀clinical฀examination฀ of฀patients฀with฀neck฀and฀radicular฀pain.฀฀ Two฀blinded฀expert฀examiners,฀who฀were฀ trained฀ together฀ in฀ the฀ identical฀ performance฀ of฀ the฀ clinical฀ tests,฀ independently฀examined฀fifty-two฀patients฀referred฀for฀ cervical฀myelography.฀฀The฀neck฀compression฀test฀was฀performed฀with฀each฀patient฀ in฀both฀supine฀and฀sitting฀positions.฀฀The฀ patient’s฀neck฀was฀passively฀flexed฀laterally฀and฀slightly฀rotated฀ipsilaterally,฀and฀the฀ head฀was฀then฀compressed฀with฀approximately฀7-Kg฀pressure.฀฀A฀positive฀test฀was฀ considered฀to฀be฀the฀appearance฀or฀aggravation฀of฀pain,฀numbness,฀or฀paresthesias฀ From Sports, Spine and Orthopedic Rehabilitation, Kessler Institute for Rehabilitation, West Orange, New Jersey; and UMDNJ - New Jersey Medical School, Newark, New Jersey. Address Correspondence: Gerard A. Malanga, MD, Kessler Institute for Rehabilitation, West Facility, 1199 Pleasant Valley Way, West Orange, New Jersey 07052. E-mail: gmalanga@pol.net. There was no outside financial support in preparation of this manuscript. Pain Physician Vol. 6, No. 2, 2003 200 Malanga et al • Provocative Tests in Spine Examination Table 1. Examination maneuvers, original description, reliability analyses and validity testing. Test Spurling’s/Neck Compression Test Original Description Passive lateral flexion, & compression of head. Positive test is reproduction of radicular symptoms distant from neck. Active abduction of symptomatic arm, Shoulder Abduction placing patient’s hand on head. Positive (Relief ) Sign test is relief or reduction of ipsilateral cervical radicular symptoms. Neck Distraction Test L’hermitte’s Sign Reliability Studies Validity Studies Viikari-Juntura (6) 1987 Viikari-Juntura et al (7) 1989 Seated position. Kappa = 0.40-0.77 Seated position. Sensitivity: 40-60% Proportion Specific Agreement = Specificity: 92-100% 0.47-0.80 Viikari-Juntura (6) 1987 Viikari-Juntura et al (7) 1989 Seated position. Kappa = 0.21-0.40 Seated position. Sensitivity: 43-50% Proportion Specific Agreement Specificity: 80-100% =0.57-0.67 Viikari-Juntura (6) 1987 Examiner grasps patient’s head under Supine position. 10-15 Kg traction occiput and chin and applies axial traction force applied. Kappa = 0.50 force. Positive test is relief or reduction of Proportion Specific Agreement cervical radicular symptoms. =0.71 Passive anterior cervical flexion. Positive test is presence of “electric-like Not reported. sensations” down spine or extremities. Viikari-Juntura et al (7) 1989 Supine position. 10-15 Kg traction force applied. Sensitivity: 40-43% Specificity: 100% Uchihara et al (4) 1994 Sensitivity: < 28% Specificity: “high” Hoffman’s Sign Passive snapping flexion of middle finger distal phalanx. Positive test is flexionNot reported. adduction of ipsilateral thumb and index finger. Glaser et al (33) 2000 Sensitivity: 58% Specificity: 78% Positive Predictive Value: 62% Negative Predictive Value 75% Adson’s Test Inspiration, chin elevation, and head rotation to affected side. Positive test is alteration or obliteration of radial pulse. Not reported. in฀ the฀ shoulder฀ or฀ upper฀ extremity.฀ For฀ the฀sitting฀position,฀Kappa฀values฀ranged฀ 0.40-0.77,฀ which฀ was฀ considered฀ to฀ be฀ “fair฀ to฀ excellent”,฀ and฀ the฀ proportion฀ of฀ specific฀agreement฀was฀found฀to฀be฀0.470.80฀which฀was฀also฀considered฀to฀be฀“fair฀ to฀ excellent.”฀ ฀ For฀ the฀ supine฀ position,฀ Kappa฀ values฀ ranged฀ 0.28-0.63,฀ which฀ was฀considered฀to฀be฀“poor฀to฀good”,฀and฀ the฀proportion฀of฀specific฀agreement฀was฀ found฀to฀be฀0.36-0.67฀which฀was฀also฀considered฀to฀be฀“poor฀to฀good”฀(6).฀฀The฀author฀concluded฀that฀this฀test฀has฀good฀reliability฀when฀performed฀in฀the฀sitting฀position.฀฀This฀is฀an฀excellent฀study฀and฀one฀ of฀the฀only฀studies฀in฀the฀literature฀assessing฀interexaminer฀reliability฀for฀the฀Spurling’s฀ Neck฀ Compression฀ test฀ and฀ other฀ provocative฀test฀maneuvers฀of฀the฀cervical฀ spine.฀ ฀ However,฀ the฀ results฀ are฀ analyzed฀ according฀to฀the฀area฀of฀symptom฀radiation฀(e.g.,฀“right฀shoulder฀or฀upper฀arm”,฀ “right฀forearm฀or฀hand”,฀“left฀shoulder฀or฀ upper฀ arm”,฀“left฀ forearm฀ or฀ hand”),฀ instead฀of฀classifying฀the฀test฀as฀positive฀or฀ negative.฀฀This฀fragments฀statistical฀analysis฀and฀makes฀interpretation฀difficult. Viikari-Juntura฀ et฀ al฀ (7)฀ published฀ a฀prospective฀study฀in฀1989฀assessing฀the฀ Pain Physician Vol. 6, No. 2, 2003 Not reported. validity฀ of฀ Spurling’s฀ Neck฀ Compression฀ Test฀in฀diagnosing฀cervical฀radiculopathy,฀ along฀with฀the฀Axial฀Manual฀Traction฀and฀ Shoulder฀ Abduction฀ tests.฀ ฀ Forty-three฀ patients฀ who฀ presented฀ for฀ myelography฀ were฀ interviewed฀ and฀ examined฀ prior฀ to฀ performing฀the฀procedure.฀฀The฀Spurling’s฀ Neck฀ Compression฀ test฀ was฀ performed฀ with฀ the฀ patient฀ sitting฀ as฀ described฀ in฀ Viikari-Juntura’s฀1987฀study฀(6).฀฀The฀criterion฀ standard฀ used฀ was฀ myelography฀ combined฀ with฀ neurologic฀ exam฀ findings.฀฀Based฀on฀the฀study฀population’s฀myelographic฀and฀clinical฀findings,฀statistical฀ analysis฀ was฀ performed฀ only฀ for฀ cervical฀ roots฀6-8.฀฀Sensitivity฀ranged฀40-60%฀and฀ specificity฀ranged฀92-100%.฀฀The฀authors฀ concluded฀that฀the฀test฀has฀high฀specificity฀but฀low฀sensitivity฀(7).฀฀As฀with฀the฀first฀ author’s฀ previous฀ study,฀ the฀ results฀ are฀ presented฀ in฀ a฀ manner฀ making฀ interpretation฀difficult.฀฀ In฀ an฀ outstanding฀ review,฀ Wainner฀ and฀Gill฀(8)฀summarize฀the฀results฀of฀the฀ Viikari-Juntura฀1987฀(6)฀and฀Viikari-Juntura,฀ et฀ al฀ 1989฀ (7)฀ studies฀ with฀ slightly฀ different฀ findings฀ reported฀ for฀ interexaminer฀reliability,฀sensitivity,฀and฀specificity฀ than฀ those฀ described฀ above,฀ although฀ the฀overall฀conclusions฀are฀similar.฀฀Tong฀ and฀Haig฀(9)฀reported฀a฀sensitivity฀of฀30%฀ and฀specificity฀of฀93%฀utilizing฀electrodiagnostic฀studies฀as฀a฀criterion฀standard฀in฀ 224฀ patients.฀ ฀ A฀ study฀ by฀ Sandmark฀ and฀ Nisell฀(10)฀reported฀a฀specificity฀of฀92%,฀ a฀sensitivity฀of฀77%,฀a฀positive฀predictive฀ value฀ of฀ 80฀ %฀ and฀ a฀ negative฀ predictive฀ value฀of฀91฀%.฀฀However,฀this฀study฀used฀ neck฀pain฀symptoms฀as฀the฀criterion฀standard.฀฀The฀neck฀compression฀test฀was฀considered฀to฀be฀positive฀if฀neck฀pain฀was฀produced.฀฀This฀is฀inconsistent฀with฀the฀original฀and฀commonly฀accepted฀descriptions฀ of฀Spurling’s฀sign.฀฀Due฀to฀these฀methodological฀ limitations฀ the฀ results฀ should฀ be฀ viewed฀ cautiously.฀ ฀ Uchihara฀ et฀ al฀ (11)฀ report฀ a฀ sensitivity฀ of฀ below฀ 28%฀ and฀ a฀ specificity฀of฀100%.฀However฀the฀criterion฀ standard฀ used฀ was฀ spinal฀ cord฀ deformity฀ on฀MRI฀in฀65฀patients. In฀ summary,฀ there฀ are฀ few฀ methodologically฀ sound฀ studies,฀ which฀ assess฀ the฀ interexaminer฀ reliability,฀ sensitivity,฀ and฀ specificity฀of฀the฀Spurling’s฀Neck฀Compression฀Test.฀฀The฀literature฀appears฀to฀indicate฀ high฀specificity฀and฀low฀sensitivity.฀฀More฀research฀is฀needed฀to฀better฀explore฀the฀utility฀ of฀this฀commonly฀used฀clinical฀test. Malanga et al • Provocative Tests in Spine Examination II. Shoulder Abduction Test Spurling฀ reportedly฀ first฀ alluded฀ to฀ the฀ Shoulder฀ Abduction฀ Test,฀ also฀ described฀as฀the฀Shoulder฀Abduction฀Relief฀ Sign,฀ in฀ a฀ monograph฀ published฀ in฀ 1956฀ (12).฀He฀states฀that฀“raising฀the฀arm฀above฀ the฀ head฀ sometimes฀ brings฀ relief ”฀ of฀ radicular฀ symptoms฀ caused฀ by฀ cervical฀ intervertebral฀ disc฀ pathology.฀ ฀ Davidson฀ et฀ al฀ (12)฀ elaborated฀ on฀ this฀ maneuver฀ in฀ 1981,฀describing฀their฀experience฀with฀22฀ patients฀ who฀ presented฀ with฀ severe฀ cervical฀ radicular฀ pain,฀ sensory,฀ and฀ motor฀ symptoms,฀initially฀unresponsive฀to฀“outpatient฀measures,”฀all฀found฀to฀have฀large฀ lateral฀ extradural฀ lesions฀ on฀ myelography.฀ ฀ Fifteen฀ (68%)฀ of฀ these฀ patients฀ experienced฀ relief฀ of฀ their฀ radicular฀ symptoms฀with฀ipsilateral฀shoulder฀abduction.฀฀ Twelve฀ of฀ 13฀ patients฀ treated฀ surgically฀ had฀relief฀of฀symptoms,฀as฀did฀the฀two฀patients฀treated฀nonsurgically.฀฀The฀authors฀ hypothesized฀that฀reduced฀nerve฀root฀tension฀is฀the฀most฀likely฀cause฀for฀symptom฀ relief฀with฀shoulder฀abduction.฀฀They฀concluded฀that฀the฀Shoulder฀Abduction฀Relief฀ Sign฀is฀indicative฀of฀nerve฀root฀compression฀ and฀ predictive฀ of฀ excellent฀ response฀ to฀surgical฀treatment฀(12). The฀ Shoulder฀Abduction฀ Relief฀ Test฀ is฀ currently฀ described฀ as฀ active฀ or฀ passive฀abduction฀of฀the฀ipsilateral฀shoulder฀ so฀that฀the฀hand฀rests฀on฀top฀of฀the฀head,฀ with฀ the฀ patient฀ either฀ sitting฀ or฀ supine.฀฀ Relief฀ or฀ reduction฀ of฀ ipsilateral฀ cervical฀ radicular฀symptoms฀is฀indicative฀of฀a฀positive฀test฀(4).฀฀In฀a฀brief฀report฀of฀three฀cases,฀Beatty฀et฀al฀(13)฀described฀this฀sign฀to฀ be฀ indicative฀ of฀ radiculopathy฀ secondary฀ to฀ cervical฀ disc฀ pathology฀ but฀ not฀ from฀ cervical฀ spondylosis.฀ ฀ Ellenberg฀ and฀ Honet฀described฀the฀Shoulder฀Abduction฀Relief฀Sign฀as฀helpful฀in฀distinguishing฀cervical฀radiculopathy฀from฀shoulder฀pathology,฀when฀present.฀฀In฀their฀experience฀the฀ sign฀is฀“frequently฀not฀present”฀with฀cervical฀radiculopathy. Viikari-Juntura฀ (6)฀ prospectively฀ studied฀ the฀ interexaminer฀ reliability฀ of฀ the฀Shoulder฀Abduction฀Relief฀Test฀in฀31฀ patients฀ as฀ described฀ in฀ section฀ I฀ above.฀฀ The฀test฀was฀performed฀in฀the฀seated฀position฀ in฀ the฀ presence฀ of฀ radicular฀ pain,฀ paresthesia,฀ or฀ numbness.฀ ฀ The฀ patient฀ was฀ instructed฀ to฀ “lift”฀ his฀ hand฀ above฀ the฀ head.฀ ฀ The฀ decrease฀ or฀ disappearance฀ of฀ radicular฀ symptoms฀ indicated฀ a฀ positive฀ test.฀ ฀ Kappa฀ scores฀ were฀ poor฀ to฀ fair฀ and฀ ranged฀ from฀ 0.21-0.40.฀ ฀ The฀ proportion฀ of฀ specific฀ agreement฀ was฀ fair฀to฀good,฀ranging฀0.57฀to฀0.67.฀฀Overall,฀ the฀ test’s฀ reliability฀ was฀ described฀ as฀ “fair”฀(6). Viikari-Juntura฀et฀al฀(7)฀as฀described฀ in฀section฀I฀above,฀investigated฀the฀validity฀of฀the฀Shoulder฀Abduction฀relief฀Test฀in฀ 1989.฀The฀test฀was฀performed฀as฀described฀ in฀the฀1987฀interexaminer฀reliability฀study฀ on฀22฀of฀the฀patients.฀฀Sensitivity฀ranged฀ from฀43%฀to฀50%฀and฀specificity฀ranged฀ from฀80%฀to฀100%.฀฀The฀authors฀concluded฀that฀the฀test฀is฀highly฀specific฀for฀cervical฀radiculopathy฀with฀low฀sensitivity.฀ The฀literature฀seems฀to฀indicate฀high฀ specificity฀ with฀ low฀ sensitivity฀ for฀ the฀ Shoulder฀Abduction฀Relief฀Test.฀However฀ the฀only฀available฀prospective฀study฀examined฀ a฀ small฀ number฀ of฀ subjects฀ for฀ this฀ test.฀ ฀ The฀ only฀ investigation฀ of฀ interexaminer฀reliability฀concluded฀the฀test฀to฀be฀ “fair”.฀฀฀Interestingly,฀incorporation฀of฀the฀ abduction฀ maneuver฀ into฀ a฀ nonsurgical฀ treatment฀program฀is฀reported฀as฀beneficial฀for฀patients฀with฀a฀positive฀test฀(14). III. Neck Distraction Test The฀Neck฀Distraction฀Test฀is฀also฀described฀as฀the฀Axial฀Manual฀Traction฀Test.฀฀ The฀origin฀of฀this฀maneuver฀is฀uncertain฀ although฀ it฀ is฀ well฀ described฀ in฀ the฀ current฀literature. “To฀perform฀the฀distraction฀test,฀the฀ examiner฀places฀one฀hand฀under฀the฀ patient’s฀ chin฀ and฀ the฀ other฀ hand฀ around฀ the฀ occiput,฀ then฀ slowly฀ lifts฀ the฀ patient’s฀ head.฀ ฀ The฀ test฀ is฀ classified฀ as฀ positive฀ if฀ the฀ pain฀ is฀ relieved฀or฀decreased฀when฀the฀head฀ is฀ lifted฀ or฀ distracted,฀ indicating฀ pressure฀on฀nerve฀roots฀that฀has฀been฀ relieved”฀(4). This฀test฀is฀commonly฀performed฀in฀ the฀supine฀position฀in฀the฀presence฀of฀radicular฀symptoms.฀฀A฀positive฀test฀is฀indicated฀by฀relief฀or฀lessening฀of฀the฀radicular฀symptoms฀(3,฀6-8).฀฀This฀is฀thought฀to฀ indicate฀cervical฀radiculopathy฀caused฀by฀ discogenic฀pathology. Viikari-Juntura฀ (6)฀ concluded฀ that฀ the฀ interexaminer฀ reliability฀ of฀ the฀ Neck฀ Distraction฀test฀is฀“good”.฀฀In฀his฀prospective฀study฀described฀in฀section฀I,฀a฀traction฀ force฀of฀10฀to฀15฀Kg฀was฀applied฀to฀29฀subjects.฀฀Kappa฀values฀were฀0.50฀and฀the฀proportion฀ of฀ specific฀ agreement฀ was฀ 0.71.฀฀ Using฀ the฀ same฀ examination฀ technique,฀ Viikari-Juntura฀et฀al฀(7)฀reported฀a฀specificity฀of฀100%฀and฀a฀sensitivity฀of฀40-43%.฀฀ The฀authors฀conclude฀that฀the฀Axial฀Manual฀Traction฀test฀has฀low฀sensitivity฀but฀is฀ 201 highly฀specific฀for฀radicular฀pain,฀and฀for฀ neurologic฀and฀radiologic฀signs฀of฀radiculopathy฀ from฀ cervical฀ disc฀ disease.฀ ฀ No฀ other฀ studies฀ of฀ interexaminer฀ reliability฀ or฀validity฀are฀reported฀in฀the฀literature. IV. L`hermitte’s Sign What฀ is฀ now฀ referred฀ to฀ as฀ L`hermitte’s฀ Sign,฀ was฀ first฀ described฀ on฀ December฀20,฀1917฀by฀Marie฀and฀Chatelin฀ (15,฀ 16).฀ ฀ They฀ reported฀ the฀ description฀ of฀“transient฀‘pins฀ and฀ needles’฀ sensations฀ traveling฀ the฀ spine฀ and฀ limbs฀ on฀ flexion฀of฀the฀head”฀in฀some฀patients฀with฀ head฀injuries฀at฀the฀meeting฀of฀the฀Centers฀ of฀ Military฀ Neurology฀ in฀ Paris฀ (15,฀ 16).฀฀ They฀ believed฀ that฀ these฀ symptoms฀ were฀ caused฀ by฀ positional฀ pressure฀ on฀ cervical฀nerve฀roots.฀฀Less฀than฀one฀month฀later,฀Babinski฀and฀Dubois฀(17)฀described฀a฀ patient฀with฀a฀Brown-Sequard฀syndrome฀ who฀ reported฀ sensations฀ of฀ ‘electric฀ discharge’฀ upon฀ flexing฀ the฀ head,฀ sneezing,฀ or฀ coughing.฀ ฀ They฀ attributed฀ the฀ symptom฀to฀the฀presence฀of฀an฀intramedullary฀ lesion.฀฀L`hermitte฀first฀wrote฀on฀this฀topic฀in฀1920฀(18)฀when฀he฀further฀elaborated฀ on฀the฀symptom’s฀origin฀in฀patients฀with฀ “concussion฀ of฀ the฀ spinal฀ cord.”฀ ฀ He฀ attributed฀these฀symptoms฀to฀posterior฀and฀ lateral฀ column฀ pathology฀ in฀ the฀ cervical฀ spinal฀ cord฀ (15,฀ 18).฀ ฀ L’hermitte฀ reported฀the฀findings฀to฀the฀Neurological฀Society฀of฀Paris฀in฀1924฀(15).฀฀This฀was฀entitled฀“Pain฀in฀the฀form฀of฀an฀Electric฀Discharge฀Character฀Following฀Head฀Flexion฀ in฀Multiple฀Sclerosis.”฀฀The฀authors฀attributed฀ the฀ “electric฀ discharge”฀ symptoms฀ to฀ demyelination฀ of฀ cervical฀ spinal฀ cord฀ segments฀and฀believed฀this฀to฀be฀an฀early฀ finding฀ in฀ multiple฀ sclerosis.฀ ฀ L`hermitte฀ wrote฀ further฀ about฀ this฀ finding฀ in฀ multiple฀ sclerosis฀ and฀ in฀ other฀ conditions฀ of฀ cervical฀spinal฀cord฀pathology฀throughout฀ his฀career฀(15).฀ L`hermitte’s฀ Sign฀ is฀ currently฀ described฀ and฀ performed฀ in฀ a฀ variety฀ of฀ ways.฀ ฀ It฀ is฀ most฀ commonly฀ described฀ as฀ passive฀ anterior฀ cervical฀ flexion฀ to฀ end฀ range฀ with฀ the฀ patient฀ seated.฀ ฀ A฀ positive฀test฀is฀indicated฀by฀the฀presence฀of฀an฀ “electric-like”฀ sensation฀ down฀ the฀ spine฀ or฀ in฀ the฀ extremities.฀ ฀ This฀ is฀ described฀ to฀occur฀with฀cervical฀spinal฀cord฀pathology฀from฀a฀wide฀variety฀of฀conditions,฀including฀Multiple฀Sclerosis,฀spinal฀cord฀tumors,฀cervical฀spondylosis,฀and฀radiation฀ myelitis฀(2,฀3,฀19).฀฀The฀test฀is฀also฀currently฀described฀as฀performed฀in฀the฀following฀ manner฀ although฀ different฀ from฀ the฀ de- Pain Physician Vol. 6, No. 2, 2003 202 scriptions฀above฀(4). “The฀patient฀is฀in฀the฀long฀leg฀sitting฀ position฀on฀the฀examining฀table.฀฀The฀ examiner฀passively฀flexes฀the฀patient’s฀ head฀ and฀ one฀ hip฀ simultaneously,฀ with฀the฀leg฀kept฀straight.฀฀A฀positive฀ test฀ occurs฀ if฀ there฀ is฀ a฀ sharp฀ pain฀ down฀ the฀ spine฀ and฀ into฀ the฀ upper฀ or฀ lower฀ limbs;฀ it฀ indicates฀ dural฀ or฀ meningeal฀ irritation฀ in฀ the฀ spine฀ or฀ possible฀cervical฀myelopathy.”฀ No฀ reports฀ investigating฀ the฀ interexaminer฀ reliability฀ of฀ L’hermitte’s฀ Sign฀ could฀ be฀ found฀ in฀ the฀ literature.฀ ฀ There฀ are฀ two฀ studies฀ describing฀ the฀ validity฀ of฀ L`hermitte’s฀ Sign,฀ although฀ both฀ have฀ methodologic฀ flaws฀ as฀ described฀ in฀ section฀I฀above.฀฀Sandmark฀and฀Nissell฀(10)฀ reported฀27%฀sensitivity,฀90%฀specificity,฀ 55%฀ positive฀ predictive฀ value,฀ and฀ 75%฀ negative฀ predictive฀ value฀ for฀ the฀ “Active฀ Flexion฀ and฀ Extension฀ Test.”฀ which฀ partly฀resembles฀L’hermitte’s฀Test.฀฀Uchihara฀et฀ al฀ (11)฀ reported฀ high฀ sensitivity฀ and฀ less฀ than฀ 28%฀ sensitivity฀ although฀ exact฀ percentages฀are฀difficult฀to฀discern.฀฀ L`hermitte’s฀Sign฀which฀was฀originally฀ described฀ anecdotally,฀ continues฀ to฀ be฀ based฀on฀anecdotal฀observation. V. Hoffmann’s Sign The฀origin฀of฀what฀is฀now฀described฀ as฀ Hoffmann’s฀ sign฀ remained฀ controversial฀through฀the฀late฀1930’s฀until฀a฀medical฀student฀named฀Otto฀Bendheim฀found฀ a฀reference฀to฀the฀reflex฀in฀a฀paper฀written฀ by฀Hans฀Curschmann฀on฀uremia฀in฀1911฀ (20,฀21).฀฀Several฀prominent฀Neurologists฀ had฀previously฀been฀unable฀to฀identify฀the฀ sign’s฀ origin.฀ ฀ In฀ 1916,฀ Keyser฀ (22)฀ published฀a฀paper฀suggesting฀the฀name฀“Hoffmann’s฀ sign”฀ be฀ dropped฀ for฀ ฀“digital฀ reflex”฀ after฀ an฀ extensive฀ search฀ failed฀ to฀ identify฀the฀origin฀of฀the฀reflex.฀฀Likewise,฀ in฀1933,฀Fay฀and฀Gotten฀published฀a฀comprehensive฀paper฀on฀the฀subject฀but฀failed฀ to฀identify฀the฀origin฀of฀the฀reflex฀(20). The฀ sign฀ is฀ attributed฀ to฀ Johann฀ Hoffmann,฀ professor฀ of฀ Neurology฀ at฀ Heidelberg,฀ Germany฀ in฀ the฀ late฀ nineteenth฀ and฀ early฀ twentieth฀ centuries,฀ a฀ pupil฀of฀Erb.฀฀Hoffmann฀was฀reported฀to฀ demonstrate฀the฀sign฀routinely฀in฀lectures฀ and฀clinics,฀although฀he฀did฀not฀discuss฀it฀ through฀publication฀(20,฀23).฀฀Hoffmann’s฀ assistant,฀Hans฀Curschmann,฀who฀became฀ professor฀of฀Medicine฀at฀the฀University฀of฀ Rostock,฀Germany,฀described฀the฀reflex฀in฀ the฀literature฀in฀1911,฀and฀named฀it฀Hoffmann’s฀ Sign฀ (21,฀ 23).฀ In฀ 1913,฀ a฀ Neurol- Pain Physician Vol. 6, No. 2, 2003 Malanga et al • Provocative Tests in Spine Examination ogist฀ in฀ Hamburg,฀ E.฀ Tromner,฀ independently฀ and฀ without฀ knowledge฀ of฀ Curschmann’s฀ paper,฀ described฀ the฀ reflex฀ as฀ well฀(20,฀21,฀24,฀25).฀฀In฀response฀to฀an฀inquiry,฀Dr.฀Curschmann฀(21)฀later฀wrote:฀ “The฀finger฀phenomenon฀mentioned฀ by฀ me฀ originates฀ from฀ Johann฀ Hoffmann,฀ Professor฀ of฀ Neurology฀ at฀Heidelberg฀(died฀1919).฀฀I฀learned฀ it฀while฀his฀pupil฀and฀assistant฀from฀ 1901฀ to฀ 1904.฀ ฀ ฀ He฀ demonstrated฀ it฀ in฀his฀classes฀and฀clinics฀as฀a฀sign฀of฀ hyperreflexia฀of฀the฀upper฀extremity.฀ So฀far฀as฀I฀know฀he฀never฀published฀ it.” Hoffmann’s฀ Sign฀ was฀ originally฀ described฀as฀follows฀(21):฀฀ “The฀test฀is฀performed฀by฀supporting฀ the฀ patient’s฀ hand฀ so฀ that฀ it฀ is฀ completely฀ relaxed฀ and฀ the฀ fingers฀ partially฀ flexed.฀ ฀ The฀ middle฀ finger฀ is฀firmly฀grasped,฀partially฀extended,฀ and฀ the฀ nail฀ snapped฀ by฀ the฀ examiner’s฀thumbnail.฀฀The฀snapping฀ should฀ be฀ done฀ with฀ considerable฀ force,฀ even฀ to฀ the฀ point฀ of฀ causing฀ pain.฀ ฀ The฀ sign฀ is฀ present฀ if฀ quick฀ flexion฀of฀both฀the฀thumb฀and฀index฀ finger฀ results.฀ ฀ Fingernails฀ other฀ than฀ the฀ middle฀ one฀ are฀ sometimes฀ selected฀ for฀ the฀ snapping.฀ ฀ The฀ sign฀ is฀ said฀ to฀ be฀ incomplete฀ if฀ only฀ the฀ thumb฀or฀only฀the฀fingers฀move.”฀ There฀ continues฀ to฀ be฀ disagreement฀ as฀ to฀ whether฀ the฀ sign฀ is฀ present฀ if฀ only฀ the฀ thumb฀ flexes,฀ as฀ advocated฀ by฀ Schneck,฀Madonick฀and฀others฀(26,฀27).฀฀Keyser฀(22)฀described฀the฀test฀to฀be฀positive฀“if฀ definite฀flexion฀of฀either฀the฀thumb฀or฀one฀ or฀more฀fingers฀results.” ฀Reportedly,฀Jakobson฀also฀described฀ a฀ similar฀ sign,฀ independently฀ and฀ after฀ Hoffmann฀ (20).฀ ฀ This฀ was฀ published฀ in฀ 1908,฀ before฀ Curschmann’s฀ paper.฀ ฀ Jakobson฀ tapped฀ the฀ distal฀ radius฀ instead฀ of฀ snapping฀the฀nail฀(20). The฀ clinical฀ significance฀ of฀ Hoffmann’s฀ Sign฀ has฀ been฀ long฀ disputed฀ (21,26,฀ 27,฀ 28).฀ ฀ In฀ a฀ comprehensive฀ review,฀Madonick฀(27)฀described฀three฀general฀ views.฀ ฀ One฀ is฀ that฀ the฀ Hoffmann’s฀ sign฀ is฀ a฀“pathologic฀ sign,฀ indicating฀ pyramidal฀ tract฀ involvement.”฀ ฀ This฀ view฀ was฀held฀by฀Keyser,฀Fay฀and฀Gotten,฀Fulton฀ and฀ Viets,฀ Perelman,฀ Echols,฀ Kastein,฀Lange,฀Madonick,฀and฀Purves-Stewart฀(27).฀฀A฀second฀view฀is฀that฀the฀Hoffmann฀sign฀“indicates฀pyramidal-tract฀involvement฀but฀that,฀owing฀to฀its฀frequent฀ presence฀ in฀ other฀ conditions,฀ its฀ clini- cal฀ value฀ is฀ doubtful.”฀ ฀ This฀ is฀ the฀ position฀supported฀by฀Schneck,฀Pitfield,฀Dana,฀ Nielsen,฀and฀Monrad฀–Krohn฀(27).฀฀Finally,฀ many฀“do฀ not฀ consider฀ the฀ Hoffmann฀ sign฀as฀pathologic฀or฀of฀any฀clinical฀value.”฀฀ This฀is฀the฀reported฀general฀view฀of฀Cooper,฀Wartenberg,฀Brain,฀Grinker฀and฀Bucy,฀ and฀Alpers฀(27).฀฀฀They฀believed฀that฀this฀ sign฀ indicated฀ a฀“state฀ of฀ increased฀ muscle฀tone”฀due฀to฀a฀variety฀of฀factors฀(27).฀ It฀appears฀that฀the฀second฀and฀third฀views฀ regarding฀ the฀ significance฀ of฀ Hoffmann’s฀ Sign฀as฀described฀by฀Madonick฀are฀actually฀similar.฀฀Pitfield฀(28)฀observed฀the฀sign฀ to฀ be฀ inconsistent฀ in฀ individual฀ patients฀ and฀ to฀ frequently฀ be฀ present฀ in฀ patients฀ with฀ cardiovascular฀ disease.฀ ฀ He฀ devised฀ a฀ scale฀ classifying฀ the฀ degree฀ in฀ which฀ the฀ response฀ follows฀ the฀ nail฀ snapping฀ into฀four฀groups,฀“plus฀1”฀to฀“plus฀4”.฀฀He฀ also฀described฀a฀maneuver฀thru฀which฀“in฀ many฀the฀reflex฀may฀be฀reinforced฀if฀present฀or฀made฀to฀appear฀if฀absent.” “The฀ upper฀ arm฀ is฀ encircled฀ by฀ the฀ cuff฀ of฀ a฀ blood฀ pressure฀ apparatus;฀ this฀is฀blown฀to฀300mm;฀if฀then฀the฀ prone฀hand฀is฀examined฀by฀snapping฀ the฀ nail฀ an฀ apparently฀ absent฀ reflex฀ will฀ become฀ positive฀ and฀ faint฀ ones฀ will฀ be฀ exalted฀ to฀ a฀ plus฀ three฀ or฀ four.฀ ฀ After฀ releasing฀ the฀ pressure฀ and฀removing฀the฀cuff,฀it฀sometimes฀ can฀ be฀ noted฀ that฀ a฀ condition฀ of฀ exultation฀ will฀ persist฀ for฀ some฀ minutes,฀the฀reflex฀being฀more฀active฀ than฀it฀was฀before฀compression.” Denno฀and฀Meadows฀(29)฀described฀ “฀the฀dynamic฀Hoffman’s฀sign”฀as฀a฀modification฀ of฀ Hoffmann’s฀ sign฀ to฀ assist฀ in฀ the฀diagnosis฀of฀early฀spondylotic฀cervical฀ myelopathy.฀฀This฀is฀performed฀by฀“multiple฀active฀full฀flexion฀to฀extension฀of฀the฀ neck”฀prior฀to฀performing฀the฀Hoffman’s฀ sign฀maneuver฀as฀originally฀described. There฀ are฀ several฀ studies฀ in฀ the฀ literature฀ investigating฀ the฀ incidence฀ of฀ Hoffmann’s฀ sign.฀ ฀ In฀ 1933,฀ Fay฀ and฀ Gotten฀ reported฀ Hoffmann’s฀ signs฀ in฀ 21฀ of฀ 393฀“supposedly฀healthy”฀college฀students฀ with฀Babinski฀signs฀in฀14.฀฀Only฀eight฀of฀ the฀21฀students฀with฀Hoffmann’s฀signs฀had฀ no฀history฀of฀brain฀injury฀or฀other฀central฀ nervous฀ system฀ pathology฀ (“sunstroke”,฀ epilepsy,฀ meningitis).฀ ฀ These฀ authors฀ also฀ noted฀ Hoffmann’s฀ signs฀ in฀ two฀ of฀ 285฀patients฀hospitalized฀in฀the฀Philadelphia฀General฀Hospital฀for฀non-neurologic฀conditions.฀฀One฀of฀these฀two฀patients฀ with฀Hoffmann’s฀signs฀also฀had฀a฀Babinski฀ sign฀(27,฀28).฀฀In฀contrast,฀of฀339฀patients฀ Malanga et al • Provocative Tests in Spine Examination hospitalized฀for฀“organic฀nervous฀disease,”฀ 139฀ had฀ Hoffmann’s฀ signs฀ and฀ 140฀ had฀ Babinski฀signs฀(28).฀฀Fay฀and฀Gotten฀concluded฀ that฀ the฀ Hoffmann฀ sign฀ indicates฀ pyramidal฀ tract฀ pathology,฀ and฀ that฀ the฀ sign฀ may฀ be฀ present฀ in฀ patients฀ without฀ a฀Babinski฀sign฀if฀“the฀lesion฀involves฀the฀ areas฀or฀fibers฀concerned฀in฀motor฀function฀of฀the฀upper฀extremity”฀(27).฀฀Echols฀ (21)฀examined฀2,017฀students฀at฀the฀University฀of฀Michigan฀and฀observed฀a฀Hoffmann’s฀sign฀in฀159฀using฀the฀lenient฀criteria฀ of฀“the฀ slightest฀ suggestion฀ of฀ flexion฀ of฀ the฀ index฀ finger,฀ the฀ thumb฀ or฀ both.”฀฀ After฀4฀months฀153฀were฀re-examined฀and฀ 32฀ patients฀ no฀ longer฀ demonstrated฀ the฀ sign,฀ 68฀ had฀ an฀“incomplete฀ Hoffmann’s฀ sign”฀with฀flexion฀of฀only฀one฀or฀more฀fingers,฀and฀53฀had฀a฀“true฀Hoffmann’s฀sign”฀ with฀flexion฀of฀both฀the฀thumb฀and฀index฀ fingers฀in฀response฀to฀snapping฀the฀middle฀finger,฀the฀ring฀finger,฀or฀both.฀฀Of฀the฀ 53฀students฀with฀“true฀Hoffmann’s฀signs,”฀ only฀33฀had฀no฀history฀of฀prior฀head฀injury฀ or฀ other฀ central฀ nervous฀ system฀ pathology฀(21,฀27).฀฀The฀incidence฀of฀a฀“true฀ Hoffmann’s฀ sign”฀ was฀ 2.62%,฀ the฀ incidence฀of฀an฀“incomplete฀Hoffmann’s฀sign”฀ was฀3.37%,฀and฀the฀incidence฀of฀an฀unexplained฀“true฀Hoffmann’s฀sign”฀was฀1.63%฀ in฀ this฀ study,฀ compared฀ with฀ a฀ 2%฀ incidence฀of฀unexplained฀Hoffmann’s฀signs฀in฀ Fay฀and฀Gotten’s฀study.฀฀Echols฀(21)฀concluded฀ that,฀ “the฀ (true)฀ Hoffmann฀ sign฀ almost฀ always฀ indicates฀ a฀ disturbance฀ of฀ the฀pyramidal฀pathway”฀and฀“the฀significance฀ of฀ an฀ incomplete฀ Hoffmann’s฀ sign฀ is฀still฀unsettled.”฀฀฀It฀should฀be฀noted฀that฀ despite฀the฀low฀incidence,฀38%฀of฀the฀patients฀ with฀ Hoffmann’s฀ signs฀ in฀ Fay฀ and฀ Gotten’s฀study฀(8/21)฀and฀62%฀of฀the฀patients฀with฀true฀Hoffman’s฀signs฀in฀Echols’฀ study฀(33/53)฀were฀unexplained. In฀ 1946,฀ Schneck฀ (26)฀ published฀ a฀ preliminary฀ report฀ of฀ a฀ “2.5-3%”฀ incidence฀ of฀ Hoffmann’s฀ sign฀ in฀ more฀ than฀ 2,500฀ subjects฀ in฀ the฀ military.฀ ฀ The฀ sign฀ was฀ unilateral฀ in฀“almost”฀ 50%.฀ ฀A฀ Hoffmann’s฀sign฀was฀defined฀as฀“flexion฀of฀the฀ thumb฀ on฀ passive฀ flexion,฀ by฀ the฀ examiner,฀of฀the฀distal฀portion฀of฀the฀patient’s฀ middle฀finger,฀with฀sudden฀release…flicking...”฀฀Reportedly,฀“in฀the฀majority฀of฀subjects฀in฀this฀study฀either฀no฀history฀of฀neurologic฀ disease฀ was฀ elicited฀ or฀ no฀ pathological฀finding฀on฀the฀neurological฀examination฀was฀found.”฀฀ Perelman฀ (27)฀ reported฀ a฀ 2%฀ incidence฀ of฀ Hoffmann’s฀ signs฀ in฀ 694฀ medical฀ students฀ and฀ registrants฀ at฀ a฀ rail- way฀technical฀school.฀฀He฀also฀reported฀a฀ 1.4฀ %฀ incidence฀ of฀ Hoffmann’s฀ sign฀ in฀ a฀ group฀of฀208฀patients฀with฀“medical,฀surgical,฀and฀peripheral฀disorders฀of฀the฀autonomic฀ nervous฀ system.”฀ ฀ Perelman฀ believed฀ that฀ a฀ Hoffmann’s฀ sign฀ is฀ clinically฀significant฀for฀pathology฀to฀the฀corticospinal฀pathway฀rostral฀to฀the฀seventh฀cervical฀segment.฀฀ In฀ 1952,฀ Madonick฀ (27)฀ published฀ a฀ comprehensive฀ study฀ of฀ 2,500฀ patients฀ with฀ non-neurologic฀ disease฀ admitted฀ to฀ the฀Morrisania฀City฀Hospital,฀and฀included฀an฀extensive฀literature฀review฀of฀Hoffmann’s฀sign.฀฀The฀sample฀was฀reported฀to฀ be฀ statistically฀ valid฀ with฀ regard฀ to฀ age,฀ but฀somewhat฀skewed฀with฀regard฀to฀gender฀ (68%฀ females),฀ and฀ race฀ (11.6%฀ Negroes).฀ ฀ A฀ Hoffmann’s฀ sign฀ was฀ considered฀ positive฀ if฀ flexion฀ of฀ the฀ thumb฀ occurred.฀ ฀ The฀ overall฀ incidence฀ of฀ Hoffmann’s฀ sign฀ was฀ found฀ to฀ be฀ 2.08%฀ (52/ 2500).฀฀The฀sign฀was฀more฀frequent฀with฀ advancing฀age.฀฀The฀incidence฀was฀0.7%฀in฀ those฀0-19,฀1.2%฀in฀those฀20-39,฀3.4%฀in฀ those฀40-59,฀and฀4%฀in฀those฀over฀60฀years฀ of฀age฀(27).฀฀Savitsky฀and฀Madonick฀(30)฀ observed฀ the฀ same฀ trend฀ for฀ the฀ Babinski฀sign฀with฀an฀overall฀4.3%฀incidence฀of฀ the฀Babinski฀sign฀in฀the฀sample.฀฀The฀incidence฀of฀Hoffman’s฀sign฀was฀5.8%฀in฀the฀ 195฀ patients฀ with฀ hypertension,฀ and฀ 0.3฀ %฀ in฀ the฀ 300฀ “psychoneurotic”฀ patients.฀ The฀sign฀was฀unilateral฀in฀60%฀of฀the฀patients฀and฀30%฀of฀the฀patients฀with฀Hoffmann’s฀signs฀had฀other฀abnormal฀findings฀ on฀exam.฀฀Madonick฀(27)฀concluded฀that,฀ “฀the฀Hoffmann฀sign฀is฀a฀sign฀of฀pyramidal฀ tract฀ involvement.”฀ However,฀ he฀ also฀ stated฀“it฀is฀difficult฀to฀determine฀whether฀the฀Hoffmann฀sign฀is฀due฀to฀functional฀ disturbance฀ of฀ the฀ pyramidal฀ tract฀ or฀ whether฀ it฀ indicates฀ only฀ a฀ state฀ of฀ increased฀ muscle฀ tone,฀ as฀ propounded฀ by฀ Wartenberg.” Sung฀ and฀ Wang฀ (31),฀ in฀ 2001,฀ prospectively฀evaluated฀16฀asymptomatic฀patients฀ with฀ a฀ positive฀ Hoffmann’s฀ reflex฀ using฀ cervical฀ radiographs฀ and฀ magnetic฀ resonance฀ imaging฀ (MRI).฀ ฀ Fourteen฀ of฀ 16฀(87.5%)฀cervical฀spine฀x-rays฀were฀abnormal฀with฀spondylosis฀and฀all฀16฀MRI’s฀ were฀interpreted฀as฀abnormal฀with฀spondylosis฀and฀cord฀compression฀in฀15.฀฀The฀ authors฀ concluded฀ that,฀“the฀ presence฀ of฀ a฀ positive฀ Hoffman’s฀ reflex฀ was฀ found฀ to฀ be฀ highly฀ associated฀ with฀ the฀ presence฀ of฀ a฀ cervical฀ spine฀ lesion฀ causing฀ neural฀ compression.”฀ ฀ Imaging฀ studies฀ or฀ further฀ evaluation฀ is฀ not฀ recommended,฀ as฀ 203 the฀ cohort฀ studied฀ remained฀ asymptomatic,฀with฀continued฀yearly฀follow-up฀(31).฀฀ This฀ study฀ is฀ limited฀ by฀ a฀ small฀ number฀ of฀ subjects฀ and฀ by฀ the฀ lack฀ of฀ a฀ control฀ group,฀although฀reference฀is฀made฀to฀other฀studies฀regarding฀the฀incidence฀of฀positive฀radiographic฀abnormalities฀in฀the฀cervical฀spines฀of฀asymptomatic฀patients.฀฀In฀ addition฀the฀authors฀did฀not฀evaluate฀for฀ possible฀brain฀pathology,฀which฀might฀be฀ responsible฀for฀the฀presence฀of฀a฀positive฀ Hoffman’s฀sign. Clinical฀ Neurology,฀ edited฀ by฀ Joynt฀ and฀Griggs฀(32),฀described฀the฀Hoffmann’s฀ sign฀as฀a฀variation฀of฀the฀finger฀flexor฀reflex,฀ indicating฀ muscle฀ stretch฀ reflex฀ hyperactivity,฀when฀present.฀฀It฀is฀described฀ to฀be฀suggestive฀of฀pyramidal฀tract฀pathology฀ rostral฀ to฀ the฀ sixth฀ cervical฀ segment,฀ especially฀ if฀ complete,฀ unilateral,฀ and฀ associated฀with฀other฀neurologic฀abnormalities.฀฀However,฀its฀presence฀is฀stated฀to฀not฀ always฀be฀indicative฀of฀pathology.฀฀It฀is฀described฀in฀association฀with฀increased฀muscle฀tone฀and฀generalized฀reflex฀hyperactivity฀to฀include฀“tension฀states.”฀฀Further,฀“an฀ incomplete฀Hoffman฀sign฀is฀encountered฀ fairly฀frequently฀in฀healthy฀persons.” There฀ are฀ no฀ known฀ studies฀ assessing฀ the฀ interexaminer฀ reliability฀ of฀ the฀ Hoffman’s฀sign.฀฀Glaser฀et฀al฀(33),฀reported฀ 58%฀ sensitivity,฀ 78%฀ specificity,฀ 62%฀ positive฀ predictive฀ value,฀ and฀ 75%฀ negative฀ predictive฀ value฀ in฀ a฀ study฀ of฀ 124฀ patients฀ presenting฀ with฀ cervical฀ complaints.฀฀Imaging฀of฀the฀cervical฀spinal฀canal฀for฀evidence฀of฀cord฀compression฀with฀ CT฀or฀MRI฀was฀used฀as฀the฀criterion฀standard.฀ ฀ When฀ only฀ results฀ of฀ the฀ patients฀ with฀cervical฀spine฀MRI’s฀were฀evaluated฀ using฀blinded฀neuroradiologists,฀the฀findings฀were฀different.฀฀For฀these฀patients,฀the฀ test฀ had฀ 33%฀ sensitivity,฀ 59%฀ specificity,฀ 26%฀ positive฀ predictive฀ value,฀ and฀ 67%฀ negative฀ predictive฀ value.฀ ฀ Authors฀ concluded฀that฀the฀Hoffman’s฀sign,฀“without฀ other฀clinical฀findings”฀is฀not฀a฀reliable฀test฀ to฀screen฀for฀cervical฀spinal฀cord฀compression.฀฀This฀retrospective฀study฀is฀useful฀despite฀its฀methodological฀flaws. In฀ summary,฀ the฀ significance฀ of฀ the฀ Hoffman’s฀ sign฀ remains฀ disputed฀ in฀ the฀ literature.฀ It฀ appears฀ to฀ be฀ indicative฀ of฀ possible฀pyramidal฀tract฀pathology.฀However,฀ it฀ may฀ be฀ present฀ with฀ generalized฀ conditions฀of฀increased฀muscular฀tone฀in฀ otherwise฀asymptomatic฀individuals฀with฀ or฀without฀recognized฀underlying฀pathology.฀฀The฀overall฀incidence฀in฀the฀population฀ appears฀ to฀ be฀ 2-3฀ %฀ with฀ differenc- Pain Physician Vol. 6, No. 2, 2003 204 es฀in฀the฀literature฀related฀to฀variability฀in฀ study฀ samples฀ and฀ in฀ the฀ precise฀ definition.฀฀The฀incidence฀of฀an฀“unexplained”฀ Hoffmann’s฀sign฀in฀the฀population,฀present฀ without฀ history฀ or฀ exam฀ findings฀ of฀ occult฀neurological฀pathology,฀is฀reported฀ to฀be฀1.5-2฀%.฀฀฀The฀validity฀has฀not฀been฀ well฀ studied฀ although฀ poor฀ to฀ fair฀ sensitivity฀ and฀ fair฀ to฀ good฀ specificity฀ are฀ reported.฀ The฀ interexaminer฀ reliability฀ has฀ not฀ been฀ reported.฀ ฀ Further฀ studies฀ exploring฀the฀validity฀and฀interexaminer฀reliability฀of฀Hoffmann’s฀sign฀are฀indicated.฀฀ VI. Adson’s Test In฀1927,฀Adson฀and฀Coffey฀(34)฀described฀a฀technique฀to฀assess฀for฀evidence฀ of฀ circulatory฀ symptoms฀ caused฀ by฀ the฀ presence฀of฀a฀cervical฀rib.฀฀“Diminution฀in฀ volume฀of฀the฀radial฀pulse฀is฀common;฀the฀ pulse฀ can฀ be฀ decreased฀ or฀ obliterated฀ by฀ having฀the฀patient฀elevate฀the฀chin฀or฀rotate฀the฀head฀to฀the฀affected฀side฀while฀inspiring฀air.฀฀This฀was฀felt฀to฀be฀due฀to฀“constriction฀of฀the฀subclavian฀artery฀or฀vein,฀ obstruction฀of฀the฀radial฀and฀ulnar฀arteries฀by฀emboli฀at฀the฀site฀of฀constriction,฀or฀ possibly฀by฀disturbance฀of฀the฀sympathetic฀ innervation.”฀ ฀ They฀ believed฀ that฀ this฀ evidence฀ of฀ circulatory฀ disturbance฀ warranted฀ consideration฀ for฀ surgical฀ resection฀of฀the฀cervical฀rib.฀฀However,฀later฀in฀ the฀ same฀ article,฀ in฀ discussing฀ the฀ cause฀ of฀the฀various฀symptoms฀in฀patients฀with฀ cervical฀ ribs,฀ Adson฀ and฀ Coffey฀ (34)฀ described฀the฀test฀somewhat฀differently. “Clinically,฀ we฀ were฀ able฀ to฀ demonstrate฀ the฀ influence฀ of฀ the฀ scalenus฀ anticus฀ muscle฀ by฀ having฀ the฀ patient฀ elevate฀ the฀ chin฀ and฀ extend฀ the฀ neck฀ or฀ rotate฀ the฀ head฀ to฀ the฀ affected฀ side฀ while฀ taking฀ a฀ deep฀ inspiration:฀ this฀ produces฀ paresthesia฀ over฀ the฀ distribution฀ of฀ the฀ brachial฀ plexus฀ and,฀ frequently,฀ obliteration฀of฀the฀pulse฀at฀the฀wrist฀ on฀the฀affected฀side.”฀ Adson฀ (35)฀ further฀ elaborated฀ on฀ this฀test฀and฀called฀it฀“The฀Vascular฀Test”฀ in฀ an฀ article฀ published฀ after฀ his฀ death฀ in฀ 1951. “The฀ test฀ consists฀ of฀ having฀ the฀ patient฀take฀a฀long฀breath,฀elevate฀his฀ chin฀and฀turn฀it฀to฀the฀affected฀side.฀฀ This฀ is฀ done฀ as฀ the฀ patient฀ is฀ seated฀ upright,฀with฀his฀arms฀resting฀on฀his฀ Pain Physician Vol. 6, No. 2, 2003 Malanga et al • Provocative Tests in Spine Examination knees.฀฀An฀alteration฀or฀obliteration฀ of฀the฀radial฀pulse฀or฀change฀in฀blood฀ pressure฀is฀a฀pathognomonic฀sign฀of฀ the฀ presence฀ of฀ a฀ cervical฀ rib฀ or฀ the฀ scalenus฀anticus฀syndrome.” Adson฀(35)฀stated฀in฀this฀article฀that฀ if฀ the฀ Vascular฀ Test฀ is฀ positive,฀ scalenotomy฀ is฀ indicated.฀ ฀ He฀ believed฀ the฀ test฀ to฀ indicate฀ subclavian฀ artery฀ compression.฀ ฀“If฀ the฀ subclavian฀ artery฀ has฀ been฀ compressed,฀ there฀ is฀ a฀ strong฀ probability฀ that฀ the฀ brachial฀ plexus฀ also฀ is฀ irritated฀ or฀ compressed฀ whenever฀ the฀ scalenus฀ anticus฀muscle฀is฀placed฀on฀tension,฀since฀ the฀ artery฀ is฀ being฀ displaced฀ posteriorly฀ against฀trunks฀of฀the฀plexus.”฀฀He฀attributed฀the฀vascular฀and฀neurologic฀symptoms฀ to฀a฀hypertrophied฀scalene฀anticus฀muscle฀ often฀but฀not฀always฀in฀the฀presence฀of฀a฀ cervical฀rib.฀฀He฀further฀stated,฀“Little฀has฀ been฀accomplished฀by฀scalenotomy฀unless฀ the฀ Vascular฀ Test฀ gives฀ a฀ positive฀ result.”฀฀ His฀ conclusions฀ were฀ based฀ on฀ personal฀ observation฀of฀operative฀findings.฀฀These฀ conclusions฀ were฀ further฀ supported฀ by฀ his฀retrospective฀review฀of฀all฀169฀patients฀ treated฀ by฀ the฀ neurosurgical฀ staff฀ at฀ the฀ Mayo฀Clinic฀from฀January฀1925฀to฀August฀ 1951฀with฀scalenotomy.฀฀Of฀these฀patients,฀ 75฀had฀scalenotomy฀without฀resection฀of฀ cervical฀ribs,฀30฀had฀scalenotomy฀and฀partial฀ rib฀ resection,฀ and฀ 64฀ had฀ scalenotomy฀ performed฀ in฀ the฀ absence฀ of฀ cervical฀ ribs.฀฀The฀operative฀findings฀revealed,฀“In฀ all฀cases฀in฀which฀the฀result฀of฀the฀vascular฀ test฀was฀positive,฀the฀scalene฀anticus฀muscle฀produced฀a฀compression฀of฀the฀subclavian฀ artery฀ on฀ each฀ inspiration.”฀ Eightyone฀ to฀ ninety฀ percent฀ of฀ all฀ patients฀ had฀ complete฀relief฀or฀“great฀improvement”฀in฀ symptoms฀following฀surgery.฀฀ Adson’s฀test฀is฀currently฀described฀in฀ the฀following฀manner฀(4):฀ “The฀patient’s฀head฀is฀rotated฀to฀face฀ the฀tested฀shoulder.฀The฀patient฀then฀ extends฀the฀head฀while฀the฀examiner฀ laterally฀ rotates฀ and฀ extends฀ the฀ patient’s฀ shoulder.฀ ฀ The฀ examiner฀ locates฀ the฀ radial฀ pulse,฀ and฀ the฀ patient฀ is฀ instructed฀ to฀ take฀ a฀ deep฀ breath฀and฀hold฀it.฀฀A฀disappearance฀ of฀the฀pulse฀is฀indicative฀of฀a฀positive฀ test.”฀ The฀interexaminer฀reliability฀and฀validity฀of฀Adson’s฀test฀have฀not฀been฀further฀ reported฀in฀the฀literature. CONCLUSION The฀majority฀of฀the฀specialized฀provocative฀tests฀commonly฀used฀in฀examination฀of฀the฀cervical฀spine฀and฀related฀neck฀ structures฀are฀purported฀to฀assist฀in฀identification฀ of฀ radiculopathy,฀ spinal฀ cord฀ pathology,฀ or฀ brachial฀ plexus฀ pathology.฀฀ Each฀of฀the฀tests฀described฀in฀this฀article฀ apparently฀originated฀from฀the฀anecdotal฀ observations฀of฀experienced,฀well฀respected฀clinicians.฀฀Few฀studies฀have฀been฀performed฀ addressing฀ the฀ interexaminer฀ reliability฀or฀validity฀of฀these฀tests.฀฀Of฀the฀ studies฀ performed,฀ most฀ were฀ not฀ methodologically฀ sound฀ or฀ had฀ other฀ limitations.฀ ฀ The฀ existing฀ literature฀ appears฀ to฀ indicate฀ high฀ specificity,฀ low฀ sensitivity,฀ and฀ good฀ to฀ fair฀ interexaminer฀ reliability฀ for฀ Spurling’s฀ Neck฀ Compression฀ test,฀ the฀Neck฀Distraction฀test,฀and฀the฀Shoulder฀ Abduction฀ (Relief)฀ test฀ when฀ performed฀ as฀ described.฀ ฀ For฀ Hoffmann’s฀ Sign,฀ the฀ existing฀ literature฀ does฀ not฀ address฀ interexaminer฀ reliability฀ but฀ appears฀ to฀ indicate฀ fair฀ sensitivity฀ and฀ fair฀ to฀good฀specificity.฀฀For฀L’hermitte’s฀Sign฀ and฀Adson’s฀test,฀not฀even฀tentative฀statements฀can฀be฀made฀with฀regard฀to฀interexaminer฀reliability,฀sensitivity,฀and฀specificity,฀based฀on฀the฀existing฀literature.฀฀It฀ should฀be฀emphasized฀that฀more฀research฀ is฀ indicated฀ to฀ understand฀ the฀ clinical฀ utility฀ of฀ all฀ of฀ these฀ tests.฀ ฀ As฀ Wainner฀ and฀ Gill฀ (8)฀ state฀ with฀ regard฀ to฀ cervical฀ radiculopathy,฀many฀investigators฀believe฀ that฀ “Given฀ the฀ paucity฀ of฀ evidence,฀ the฀ true฀value฀of฀the฀clinical฀examination…is฀ unknown฀at฀this฀time.”฀฀ Common฀ consensus฀ appears฀ to฀ be฀ that฀ none฀ of฀ the฀ specialized฀ provocative฀ tests฀ used฀ in฀ examination฀ of฀ the฀ cervical฀ spine฀ has฀ the฀ reliability,฀ sensitivity,฀ and฀specificity฀to฀determine฀the฀presence฀ or฀ absence฀ of฀ specific฀ cervical฀ pathology,฀ in฀ isolation.฀ ฀ They฀ appear฀ to฀ have฀ greatest฀ clinical฀ utility฀ in฀ the฀ context฀ of฀ the฀ patient’s฀ clinical฀ history฀ and฀ other฀ exam฀ findings.฀ ฀ As฀ Schneck฀ (26)฀ stated฀ regarding฀ Hoffmann’s฀ Sign,฀ “the…sign฀ as฀ a฀ positive฀ indication฀ of฀ organic฀ pathology฀ would฀ seem฀ to฀ bear฀ greater฀ significance฀when฀accompanied฀by฀a฀suggestive฀ history฀ or฀ by฀ other฀ pathological฀ signs฀ or฀ symptoms.”฀฀฀฀ Malanga et al • Provocative Tests in Spine Examination Author฀Affiliation Gerard฀A.฀Malanga,฀MD Kessler฀ Institute฀ for฀ Rehabilitation,฀ West฀ Facility,฀ 1199฀ Pleasant฀ Valley฀ Way,฀West฀Orange,฀New฀Jersey฀฀07052,฀ (973)฀ 736-9090,฀ fax฀ (973)฀ 243-6861฀ or฀E-mail:฀฀gmalanga@pol.net Phillip฀Landes,฀MD Kessler฀ Institute฀ for฀ Rehabilitation,฀ West฀ Facility,฀ 1199฀ Pleasant฀ Valley฀ Way,฀ West฀ Orange,฀ New฀ Jersey฀ ฀ 07052,฀ (973)฀ 736-9090,฀ fax฀ (973)฀ 243-6861 Scott฀F.฀Nadler,฀DO UMDNJ฀ –฀ New฀ Jersey฀ Medical฀ School,฀Doctors฀Office฀Center,฀Newark,฀New฀Jersey฀ REFERENCES 1. 2. 3. 4. 5. 6. 7. 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