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 examinationoftheneckandcervicalspine.The
majority of these relate to identification
of radiculopathy, spinal cord pathology,
orbrachialplexuspathology.Thesetests
are often performed routinely by many
providers with variable methods and interpretedinavarietyofways.
Thepurposeofthisreviewistodescribe several commonly performed specialized provocative tests used in examinationoftheneckandcervicalspineregions.Foreachtest,theorigin,technique,
reliability, validity, and clinical significance are discussed, based on a comprehensive search of the existing literature.
Thegoalistodevelopstandardizationin
theperformanceandclinicaluseofthese
tests.
I. Spurling’s Neck Compression Test
SpurlingandScovillefirstdescribed
Spurling’s Neck Compression Test, also
known as, the Foraminal Compression
Test,NeckCompressionTest,orQuadrant
Test,in1944as“themostimportantdiagnostictestandonethatisalmostpathognomonic of a cervical intraspinal lesion”
(1).Theirobservationswerebasedonthe
presentationof12patientswith“ruptured
cervical discs” verified during surgery in
1943atWalterReedArmyHospital.The
authors state that during the same period many more of these cases were diagnosed but not verified surgically. They
described“theneckcompressiontest”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
thesymptoms.Tiltingtheheadaway
fromthelesionusuallygivesrelief.”
Currently the test is described as
“performedbyextendingtheneckandrotatingtheheadandthenapplyingdownward pressure on the head. The test is
considered positive if pain radiates into
the limb ipsilateral to the side at which
theheadisrotated”(2).Someauthorsadvocateperformingthecomponentsofthe
testinastagedmannerandhaltingwith
the onset of radicular symptoms, preferablyreproducingthepatient’spresenting
symptoms(3-5).Radicularsymptomsare
described as pain or paresthesias occurring distant from the neck, in the distributionofacervicalspinalnerveroot.
Vikari-Juntura(6)performedaprospectivestudyin1987toassesstheinterexaminerreliabilityofcommontestsgenerallyperformedintheclinicalexamination
ofpatientswithneckandradicularpain.
Twoblindedexpertexaminers,whowere
trained together in the identical performance of the clinical tests, independentlyexaminedfifty-twopatientsreferredfor
cervicalmyelography.Theneckcompressiontestwasperformedwitheachpatient
inbothsupineandsittingpositions.The
patient’sneckwaspassivelyflexedlaterallyandslightlyrotatedipsilaterally,andthe
headwasthencompressedwithapproximately7-Kgpressure.Apositivetestwas
consideredtobetheappearanceoraggravationofpain,numbness,orparesthesias
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
thesittingposition,Kappavaluesranged
0.40-0.77, which was considered to be
“fair to excellent”, and the proportion of
specificagreementwasfoundtobe0.470.80whichwasalsoconsideredtobe“fair
to excellent.” For the supine position,
Kappa values ranged 0.28-0.63, which
wasconsideredtobe“poortogood”,and
theproportionofspecificagreementwas
foundtobe0.36-0.67whichwasalsoconsideredtobe“poortogood”(6).Theauthorconcludedthatthistesthasgoodreliabilitywhenperformedinthesittingposition.Thisisanexcellentstudyandone
oftheonlystudiesintheliteratureassessinginterexaminerreliabilityfortheSpurling’s Neck Compression test and other
provocativetestmaneuversofthecervical
spine. However, the results are analyzed
accordingtotheareaofsymptomradiation(e.g.,“rightshoulderorupperarm”,
“rightforearmorhand”,“leftshoulderor
upper arm”,“left forearm or hand”), insteadofclassifyingthetestaspositiveor
negative.Thisfragmentsstatisticalanalysisandmakesinterpretationdifficult.
Viikari-Juntura et al (7) published
aprospectivestudyin1989assessingthe
Pain Physician Vol. 6, No. 2, 2003
Not reported.
validity of Spurling’s Neck Compression
Testindiagnosingcervicalradiculopathy,
alongwiththeAxialManualTractionand
Shoulder Abduction tests. Forty-three
patients who presented for myelography
were interviewed and examined prior to
performingtheprocedure.TheSpurling’s
Neck Compression test was performed
with the patient sitting as described in
Viikari-Juntura’s1987study(6).Thecriterion standard used was myelography
combined with neurologic exam findings.Basedonthestudypopulation’smyelographicandclinicalfindings,statistical
analysis was performed only for cervical
roots6-8.Sensitivityranged40-60%and
specificityranged92-100%.Theauthors
concludedthatthetesthashighspecificitybutlowsensitivity(7).Aswiththefirst
author’s previous study, the results are
presented in a manner making interpretationdifficult.
In an outstanding review, Wainner
andGill(8)summarizetheresultsofthe
Viikari-Juntura1987(6)andViikari-Juntura, et al 1989 (7) studies with slightly
different findings reported for interexaminerreliability,sensitivity,andspecificity than those described above, although
theoverallconclusionsaresimilar.Tong
andHaig(9)reportedasensitivityof30%
andspecificityof93%utilizingelectrodiagnosticstudiesasacriterionstandardin
224 patients. A study by Sandmark and
Nisell(10)reportedaspecificityof92%,
asensitivityof77%,apositivepredictive
value of 80 % and a negative predictive
valueof91%.However,thisstudyused
neckpainsymptomsasthecriterionstandard.Theneckcompressiontestwasconsideredtobepositiveifneckpainwasproduced.Thisisinconsistentwiththeoriginalandcommonlyaccepteddescriptions
ofSpurling’ssign.Duetothesemethodological limitations the results should be
viewed cautiously. Uchihara et al (11)
report a sensitivity of below 28% and a
specificityof100%.Howeverthecriterion
standard used was spinal cord deformity
onMRIin65patients.
In summary, there are few methodologically sound studies, which assess the
interexaminer reliability, sensitivity, and
specificityoftheSpurling’sNeckCompressionTest.Theliteratureappearstoindicate
highspecificityandlowsensitivity.Moreresearchisneededtobetterexploretheutility
ofthiscommonlyusedclinicaltest.
Malanga et al • Provocative Tests in Spine Examination
II. Shoulder Abduction Test
Spurling reportedly first alluded to
the Shoulder Abduction Test, also describedastheShoulderAbductionRelief
Sign, in a monograph published in 1956
(12).Hestatesthat“raisingthearmabove
the head sometimes brings relief ” of radicular symptoms caused by cervical intervertebral disc pathology. Davidson et
al (12) elaborated on this maneuver in
1981,describingtheirexperiencewith22
patients who presented with severe cervical radicular pain, sensory, and motor
symptoms,initiallyunresponsiveto“outpatientmeasures,”allfoundtohavelarge
lateral extradural lesions on myelography. Fifteen (68%) of these patients experienced relief of their radicular symptomswithipsilateralshoulderabduction.
Twelve of 13 patients treated surgically
hadreliefofsymptoms,asdidthetwopatientstreatednonsurgically.Theauthors
hypothesizedthatreducednerveroottensionisthemostlikelycauseforsymptom
reliefwithshoulderabduction.TheyconcludedthattheShoulderAbductionRelief
Signisindicativeofnerverootcompression and predictive of excellent response
tosurgicaltreatment(12).
The ShoulderAbduction Relief Test
is currently described as active or passiveabductionoftheipsilateralshoulder
sothatthehandrestsontopofthehead,
with the patient either sitting or supine.
Relief or reduction of ipsilateral cervical
radicularsymptomsisindicativeofapositivetest(4).Inabriefreportofthreecases,Beattyetal(13)describedthissignto
be indicative of radiculopathy secondary
to cervical disc pathology but not from
cervical spondylosis. Ellenberg and HonetdescribedtheShoulderAbductionReliefSignashelpfulindistinguishingcervicalradiculopathyfromshoulderpathology,whenpresent.Intheirexperiencethe
signis“frequentlynotpresent”withcervicalradiculopathy.
Viikari-Juntura (6) prospectively
studied the interexaminer reliability of
theShoulderAbductionReliefTestin31
patients as described in section I above.
Thetestwasperformedintheseatedposition 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
fairtogood,ranging0.57to0.67.Overall, the test’s reliability was described as
“fair”(6).
Viikari-Junturaetal(7)asdescribed
insectionIabove,investigatedthevalidityoftheShoulderAbductionreliefTestin
1989.Thetestwasperformedasdescribed
inthe1987interexaminerreliabilitystudy
on22ofthepatients.Sensitivityranged
from43%to50%andspecificityranged
from80%to100%.Theauthorsconcludedthatthetestishighlyspecificforcervicalradiculopathywithlowsensitivity.
Theliteratureseemstoindicatehigh
specificity with low sensitivity for the
ShoulderAbductionReliefTest.However
theonlyavailableprospectivestudyexamined a small number of subjects for this
test. The only investigation of interexaminerreliabilityconcludedthetesttobe
“fair”.Interestingly,incorporationofthe
abduction maneuver into a nonsurgical
treatmentprogramisreportedasbeneficialforpatientswithapositivetest(14).
III. Neck Distraction Test
TheNeckDistractionTestisalsodescribedastheAxialManualTractionTest.
Theoriginofthismaneuverisuncertain
although it is well described in the currentliterature.
“Toperformthedistractiontest,the
examinerplacesonehandunderthe
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
relievedordecreasedwhenthehead
is lifted or distracted, indicating
pressureonnerverootsthathasbeen
relieved”(4).
Thistestiscommonlyperformedin
thesupinepositioninthepresenceofradicularsymptoms.Apositivetestisindicatedbyrelieforlesseningoftheradicularsymptoms(3,6-8).Thisisthoughtto
indicatecervicalradiculopathycausedby
discogenicpathology.
Viikari-Juntura (6) concluded that
the interexaminer reliability of the Neck
Distractiontestis“good”.InhisprospectivestudydescribedinsectionI,atraction
forceof10to15Kgwasappliedto29subjects.Kappavalueswere0.50andtheproportion of specific agreement was 0.71.
Using the same examination technique,
Viikari-Junturaetal(7)reportedaspecificityof100%andasensitivityof40-43%.
TheauthorsconcludethattheAxialManualTractiontesthaslowsensitivitybutis
201
highlyspecificforradicularpain,andfor
neurologicandradiologicsignsofradiculopathy from cervical disc disease. No
other studies of interexaminer reliability
orvalidityarereportedintheliterature.
IV. L`hermitte’s Sign
What is now referred to as
L`hermitte’s Sign, was first described on
December20,1917byMarieandChatelin (15, 16). They reported the description of“transient‘pins and needles’ sensations traveling the spine and limbs on
flexionofthehead”insomepatientswith
headinjuriesatthemeetingoftheCenters
of Military Neurology in Paris (15, 16).
They believed that these symptoms were
caused by positional pressure on cervicalnerveroots.Lessthanonemonthlater,BabinskiandDubois(17)describeda
patientwithaBrown-Sequardsyndrome
who reported sensations of ‘electric discharge’ upon flexing the head, sneezing,
or coughing. They attributed the symptomtothepresenceofanintramedullary
lesion.L`hermittefirstwroteonthistopicin1920(18)whenhefurtherelaborated
onthesymptom’sorigininpatientswith
“concussion of the spinal cord.” He attributedthesesymptomstoposteriorand
lateral column pathology in the cervical
spinal cord (15, 18). L’hermitte reportedthefindingstotheNeurologicalSocietyofParisin1924(15).Thiswasentitled“PainintheformofanElectricDischargeCharacterFollowingHeadFlexion
inMultipleSclerosis.”Theauthorsattributed the “electric discharge” symptoms
to demyelination of cervical spinal cord
segmentsandbelievedthistobeanearly
finding in multiple sclerosis. L`hermitte
wrote further about this finding in multiple sclerosis and in other conditions of
cervicalspinalcordpathologythroughout
hiscareer(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 positivetestisindicatedbythepresenceofan
“electric-like” sensation down the spine
or in the extremities. This is described
tooccurwithcervicalspinalcordpathologyfromawidevarietyofconditions,includingMultipleSclerosis,spinalcordtumors,cervicalspondylosis,andradiation
myelitis(2,3,19).Thetestisalsocurrentlydescribedasperformedinthefollowing
manner although different from the de-
Pain Physician Vol. 6, No. 2, 2003
202
scriptionsabove(4).
“Thepatientisinthelonglegsitting
positionontheexaminingtable.The
examinerpassivelyflexesthepatient’s
head and one hip simultaneously,
withthelegkeptstraight.Apositive
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
possiblecervicalmyelopathy.”
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 sectionIabove.SandmarkandNissell(10)
reported27%sensitivity,90%specificity,
55% positive predictive value, and 75%
negative predictive value for the “Active
Flexion and Extension Test.” which partlyresemblesL’hermitte’sTest.Uchiharaet
al (11) reported high sensitivity and less
than 28% sensitivity although exact percentagesaredifficulttodiscern.
L`hermitte’sSignwhichwasoriginally described anecdotally, continues to be
basedonanecdotalobservation.
V. Hoffmann’s Sign
Theoriginofwhatisnowdescribed
as Hoffmann’s sign remained controversialthroughthelate1930’suntilamedicalstudentnamedOttoBendheimfound
areferencetothereflexinapaperwritten
byHansCurschmannonuremiain1911
(20,21).SeveralprominentNeurologists
hadpreviouslybeenunabletoidentifythe
sign’s origin. In 1916, Keyser (22) publishedapapersuggestingthename“Hoffmann’s sign” be dropped for “digital reflex” after an extensive search failed to
identifytheoriginofthereflex.Likewise,
in1933,FayandGottenpublishedacomprehensivepaperonthesubjectbutfailed
toidentifytheoriginofthereflex(20).
The sign is attributed to Johann
Hoffmann, professor of Neurology at
Heidelberg, Germany in the late nineteenth and early twentieth centuries, a
pupilofErb.Hoffmannwasreportedto
demonstratethesignroutinelyinlectures
andclinics,althoughhedidnotdiscussit
throughpublication(20,23).Hoffmann’s
assistant,HansCurschmann,whobecame
professorofMedicineattheUniversityof
Rostock,Germany,describedthereflexin
theliteraturein1911,andnameditHoffmann’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).Inresponsetoaninquiry,Dr.Curschmann(21)laterwrote:
“Thefingerphenomenonmentioned
by me originates from Johann
Hoffmann, Professor of Neurology
atHeidelberg(died1919).Ilearned
itwhilehispupilandassistantfrom
1901 to 1904. He demonstrated it
inhisclassesandclinicsasasignof
hyperreflexiaoftheupperextremity.
SofarasIknowheneverpublished
it.”
Hoffmann’s Sign was originally describedasfollows(21):
“Thetestisperformedbysupporting
the patient’s hand so that it is
completely relaxed and the fingers
partially flexed. The middle finger
isfirmlygrasped,partiallyextended,
and the nail snapped by the
examiner’sthumbnail.Thesnapping
should be done with considerable
force, even to the point of causing
pain. The sign is present if quick
flexionofboththethumbandindex
finger results. Fingernails other
than the middle one are sometimes
selected for the snapping. The sign
is said to be incomplete if only the
thumboronlythefingersmove.”
There continues to be disagreement
as to whether the sign is present if only
the thumb flexes, as advocated by Schneck,Madonickandothers(26,27).Keyser(22)describedthetesttobepositive“if
definiteflexionofeitherthethumborone
ormorefingersresults.”
Reportedly,Jakobsonalsodescribed
a similar sign, independently and after
Hoffmann (20). This was published in
1908, before Curschmann’s paper. Jakobson tapped the distal radius instead of
snappingthenail(20).
The clinical significance of Hoffmann’s Sign has been long disputed
(21,26, 27, 28). In a comprehensive review,Madonick(27)describedthreegeneral views. One is that the Hoffmann’s
sign is a“pathologic sign, indicating pyramidal tract involvement.” This view
washeldbyKeyser,FayandGotten,Fulton and Viets, Perelman, Echols, Kastein,Lange,Madonick,andPurves-Stewart(27).AsecondviewisthattheHoffmannsign“indicatespyramidal-tractinvolvementbutthat,owingtoitsfrequent
presence in other conditions, its clini-
cal value is doubtful.” This is the positionsupportedbySchneck,Pitfield,Dana,
Nielsen,andMonrad–Krohn(27).Finally, many“do not consider the Hoffmann
signaspathologicorofanyclinicalvalue.”
ThisisthereportedgeneralviewofCooper,Wartenberg,Brain,GrinkerandBucy,
andAlpers(27).Theybelievedthatthis
sign indicated a“state of increased muscletone”duetoavarietyoffactors(27).
Itappearsthatthesecondandthirdviews
regarding the significance of Hoffmann’s
SignasdescribedbyMadonickareactuallysimilar.Pitfield(28)observedthesign
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
intofourgroups,“plus1”to“plus4”.He
alsodescribedamaneuverthruwhich“in
manythereflexmaybereinforcedifpresentormadetoappearifabsent.”
“The upper arm is encircled by the
cuff of a blood pressure apparatus;
thisisblownto300mm;ifthenthe
pronehandisexaminedbysnapping
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
andremovingthecuff,itsometimes
can be noted that a condition of
exultation will persist for some
minutes,thereflexbeingmoreactive
thanitwasbeforecompression.”
DennoandMeadows(29)described
“thedynamicHoffman’ssign”asamodification of Hoffmann’s sign to assist in
thediagnosisofearlyspondyloticcervical
myelopathy.Thisisperformedby“multipleactivefullflexiontoextensionofthe
neck”priortoperformingtheHoffman’s
signmaneuverasoriginallydescribed.
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“supposedlyhealthy”collegestudents
withBabinskisignsin14.Onlyeightof
the21studentswithHoffmann’ssignshad
nohistoryofbraininjuryorothercentral
nervous system pathology (“sunstroke”,
epilepsy, meningitis). These authors
also noted Hoffmann’s signs in two of
285patientshospitalizedinthePhiladelphiaGeneralHospitalfornon-neurologicconditions.Oneofthesetwopatients
withHoffmann’ssignsalsohadaBabinski
sign(27,28).Incontrast,of339patients
Malanga et al • Provocative Tests in Spine Examination
hospitalizedfor“organicnervousdisease,”
139 had Hoffmann’s signs and 140 had
Babinskisigns(28).FayandGottenconcluded that the Hoffmann sign indicates
pyramidal tract pathology, and that the
sign may be present in patients without
aBabinskisignif“thelesioninvolvesthe
areasorfibersconcernedinmotorfunctionoftheupperextremity”(27).Echols
(21)examined2,017studentsattheUniversityofMichiganandobservedaHoffmann’ssignin159usingthelenientcriteria of“the slightest suggestion of flexion
of the index finger, the thumb or both.”
After4months153werere-examinedand
32 patients no longer demonstrated the
sign, 68 had an“incomplete Hoffmann’s
sign”withflexionofonlyoneormorefingers,and53hada“trueHoffmann’ssign”
withflexionofboththethumbandindex
fingersinresponsetosnappingthemiddlefinger,theringfinger,orboth.Ofthe
53studentswith“trueHoffmann’ssigns,”
only33hadnohistoryofpriorheadinjury or other central nervous system pathology(21,27).Theincidenceofa“true
Hoffmann’s sign” was 2.62%, the incidenceofan“incompleteHoffmann’ssign”
was3.37%,andtheincidenceofanunexplained“trueHoffmann’ssign”was1.63%
in this study, compared with a 2% incidenceofunexplainedHoffmann’ssignsin
FayandGotten’sstudy.Echols(21)concluded that, “the (true) Hoffmann sign
almost always indicates a disturbance of
thepyramidalpathway”and“thesignificance of an incomplete Hoffmann’s sign
isstillunsettled.”Itshouldbenotedthat
despitethelowincidence,38%ofthepatients with Hoffmann’s signs in Fay and
Gotten’sstudy(8/21)and62%ofthepatientswithtrueHoffman’ssignsinEchols’
study(33/53)wereunexplained.
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’ssignwasdefinedas“flexionofthe
thumb on passive flexion, by the examiner,ofthedistalportionofthepatient’s
middlefinger,withsuddenrelease…flicking...”Reportedly,“inthemajorityofsubjectsinthisstudyeithernohistoryofneurologic disease was elicited or no pathologicalfindingontheneurologicalexaminationwasfound.”
Perelman (27) reported a 2% incidence of Hoffmann’s signs in 694 medical students and registrants at a rail-
waytechnicalschool.Healsoreporteda
1.4 % incidence of Hoffmann’s sign in a
groupof208patientswith“medical,surgical,andperipheraldisordersoftheautonomic nervous system.” Perelman believed that a Hoffmann’s sign is clinicallysignificantforpathologytothecorticospinalpathwayrostraltotheseventhcervicalsegment.
In 1952, Madonick (27) published
a comprehensive study of 2,500 patients
with non-neurologic disease admitted to
theMorrisaniaCityHospital,andincludedanextensiveliteraturereviewofHoffmann’ssign.Thesamplewasreportedto
be statistically valid with regard to age,
butsomewhatskewedwithregardtogender (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).Thesignwasmorefrequentwith
advancingage.Theincidencewas0.7%in
those0-19,1.2%inthose20-39,3.4%in
those40-59,and4%inthoseover60years
ofage(27).SavitskyandMadonick(30)
observed the same trend for the Babinskisignwithanoverall4.3%incidenceof
theBabinskisigninthesample.TheincidenceofHoffman’ssignwas5.8%inthe
195 patients with hypertension, and 0.3
% in the 300 “psychoneurotic” patients.
Thesignwasunilateralin60%ofthepatientsand30%ofthepatientswithHoffmann’ssignshadotherabnormalfindings
onexam.Madonick(27)concludedthat,
“theHoffmannsignisasignofpyramidal tract involvement.” However, he also
stated“itisdifficulttodeterminewhethertheHoffmannsignisduetofunctional 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, prospectivelyevaluated16asymptomaticpatients with a positive Hoffmann’s reflex
using cervical radiographs and magnetic
resonance imaging (MRI). Fourteen of
16(87.5%)cervicalspinex-rayswereabnormalwithspondylosisandall16MRI’s
wereinterpretedasabnormalwithspondylosisandcordcompressionin15.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,withcontinuedyearlyfollow-up(31).
This study is limited by a small number
of subjects and by the lack of a control
group,althoughreferenceismadetootherstudiesregardingtheincidenceofpositiveradiographicabnormalitiesinthecervicalspinesofasymptomaticpatients.In
additiontheauthorsdidnotevaluatefor
possiblebrainpathology,whichmightbe
responsibleforthepresenceofapositive
Hoffman’ssign.
Clinical Neurology, edited by Joynt
andGriggs(32),describedtheHoffmann’s
signasavariationofthefingerflexorreflex, indicating muscle stretch reflex hyperactivity,whenpresent.Itisdescribed
tobesuggestiveofpyramidaltractpathology rostral to the sixth cervical segment,
especially if complete, unilateral, and associatedwithotherneurologicabnormalities.However,itspresenceisstatedtonot
alwaysbeindicativeofpathology.Itisdescribedinassociationwithincreasedmuscletoneandgeneralizedreflexhyperactivitytoinclude“tensionstates.”Further,“an
incompleteHoffmansignisencountered
fairlyfrequentlyinhealthypersons.”
There are no known studies assessing the interexaminer reliability of the
Hoffman’ssign.Glaseretal(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.Imagingofthecervicalspinalcanalforevidenceofcordcompressionwith
CTorMRIwasusedasthecriterionstandard. When only results of the patients
withcervicalspineMRI’swereevaluated
usingblindedneuroradiologists,thefindingsweredifferent.Forthesepatients,the
test had 33% sensitivity, 59% specificity,
26% positive predictive value, and 67%
negative predictive value. Authors concludedthattheHoffman’ssign,“without
otherclinicalfindings”isnotareliabletest
toscreenforcervicalspinalcordcompression.Thisretrospectivestudyisusefuldespiteitsmethodologicalflaws.
In summary, the significance of the
Hoffman’s sign remains disputed in the
literature. It appears to be indicative of
possiblepyramidaltractpathology.However, it may be present with generalized
conditionsofincreasedmusculartonein
otherwiseasymptomaticindividualswith
orwithoutrecognizedunderlyingpathology.Theoverallincidenceinthepopulation appears to be 2-3 % with differenc-
Pain Physician Vol. 6, No. 2, 2003
204
esintheliteraturerelatedtovariabilityin
study samples and in the precise definition.Theincidenceofan“unexplained”
Hoffmann’ssigninthepopulation,present without history or exam findings of
occultneurologicalpathology,isreported
tobe1.5-2%.Thevalidityhasnotbeen
well studied although poor to fair sensitivity and fair to good specificity are reported. The interexaminer reliability has
not been reported. Further studies exploringthevalidityandinterexaminerreliabilityofHoffmann’ssignareindicated.
VI. Adson’s Test
In1927,AdsonandCoffey(34)describedatechniquetoassessforevidence
of circulatory symptoms caused by the
presenceofacervicalrib.“Diminutionin
volumeoftheradialpulseiscommon;the
pulse can be decreased or obliterated by
havingthepatientelevatethechinorrotatetheheadtotheaffectedsidewhileinspiringair.Thiswasfelttobedueto“constrictionofthesubclavianarteryorvein,
obstructionoftheradialandulnararteriesbyemboliatthesiteofconstriction,or
possiblybydisturbanceofthesympathetic innervation.” They believed that this
evidence of circulatory disturbance warranted consideration for surgical resectionofthecervicalrib.However,laterin
the same article, in discussing the cause
ofthevarioussymptomsinpatientswith
cervical ribs, Adson and Coffey (34) describedthetestsomewhatdifferently.
“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,
obliterationofthepulseatthewrist
ontheaffectedside.”
Adson (35) further elaborated on
thistestandcalledit“TheVascularTest”
in an article published after his death in
1951.
“The test consists of having the
patienttakealongbreath,elevatehis
chinandturnittotheaffectedside.
This is done as the patient is seated
upright,withhisarmsrestingonhis
Pain Physician Vol. 6, No. 2, 2003
Malanga et al • Provocative Tests in Spine Examination
knees.Analterationorobliteration
oftheradialpulseorchangeinblood
pressureisapathognomonicsignof
the presence of a cervical rib or the
scalenusanticussyndrome.”
Adson(35)statedinthisarticlethat
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
anticusmuscleisplacedontension,since
the artery is being displaced posteriorly
againsttrunksoftheplexus.”Heattributedthevascularandneurologicsymptoms
toahypertrophiedscaleneanticusmuscle
oftenbutnotalwaysinthepresenceofa
cervicalrib.Hefurtherstated,“Littlehas
beenaccomplishedbyscalenotomyunless
the Vascular Test gives a positive result.”
His conclusions were based on personal
observationofoperativefindings.These
conclusions were further supported by
hisretrospectivereviewofall169patients
treated by the neurosurgical staff at the
MayoClinicfromJanuary1925toAugust
1951withscalenotomy.Ofthesepatients,
75hadscalenotomywithoutresectionof
cervicalribs,30hadscalenotomyandpartial rib resection, and 64 had scalenotomy performed in the absence of cervical
ribs.Theoperativefindingsrevealed,“In
allcasesinwhichtheresultofthevascular
testwaspositive,thescaleneanticusmuscleproducedacompressionofthesubclavian artery on each inspiration.” Eightyone to ninety percent of all patients had
completereliefor“greatimprovement”in
symptomsfollowingsurgery.
Adson’stestiscurrentlydescribedin
thefollowingmanner(4):
“Thepatient’sheadisrotatedtoface
thetestedshoulder.Thepatientthen
extendstheheadwhiletheexaminer
laterally rotates and extends the
patient’s shoulder. The examiner
locates the radial pulse, and the
patient is instructed to take a deep
breathandholdit.Adisappearance
ofthepulseisindicativeofapositive
test.”
TheinterexaminerreliabilityandvalidityofAdson’stesthavenotbeenfurther
reportedintheliterature.
CONCLUSION
Themajorityofthespecializedprovocativetestscommonlyusedinexaminationofthecervicalspineandrelatedneck
structuresarepurportedtoassistinidentification of radiculopathy, spinal cord
pathology, or brachial plexus pathology.
Eachofthetestsdescribedinthisarticle
apparentlyoriginatedfromtheanecdotal
observationsofexperienced,wellrespectedclinicians.Fewstudieshavebeenperformed addressing the interexaminer reliabilityorvalidityofthesetests.Ofthe
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,
theNeckDistractiontest,andtheShoulder 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
togoodspecificity.ForL’hermitte’sSign
andAdson’stest,notevententativestatementscanbemadewithregardtointerexaminerreliability,sensitivity,andspecificity,basedontheexistingliterature.It
shouldbeemphasizedthatmoreresearch
is indicated to understand the clinical
utility of all of these tests. As Wainner
and Gill (8) state with regard to cervical
radiculopathy,manyinvestigatorsbelieve
that “Given the paucity of evidence, the
truevalueoftheclinicalexamination…is
unknownatthistime.”
Common consensus appears to be
that none of the specialized provocative
tests used in examination of the cervical spine has the reliability, sensitivity,
andspecificitytodeterminethepresence
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 significancewhenaccompaniedbyasuggestive
history or by other pathological signs or
symptoms.”
Malanga et al • Provocative Tests in Spine Examination
AuthorAffiliation
GerardA.Malanga,MD
Kessler Institute for Rehabilitation,
West Facility, 1199 Pleasant Valley
Way,WestOrange,NewJersey07052,
(973) 736-9090, fax (973) 243-6861
orE-mail:gmalanga@pol.net
PhillipLandes,MD
Kessler Institute for Rehabilitation,
West Facility, 1199 Pleasant Valley Way, West Orange, New Jersey
07052, (973) 736-9090, fax (973)
243-6861
ScottF.Nadler,DO
UMDNJ – New Jersey Medical
School,DoctorsOfficeCenter,Newark,NewJersey
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