This rigorously conducted review concluded that, where consistent with clinical history and examination, a positive Spurling's test, traction/neck distraction test and Valsalva manoeuvre may suggest cervical radiculopathy while a negative upper limb tension test may rule it out. These conclusions are broadly consistent with the reported results. However, there were no data on the combined performance of tests.

To assess the diagnostic accuracy of provocative tests of the neck for diagnosing cervical radiculopathy.

MEDLINE, EMBASE, CINAHL, MEDION, OSTMED and DARE were searched in June 2005. The reference lists of retrieved articles were checked and trial authors were contacted for additional studies. No search filters were used and the search strategy was reported in full. No language or publication date restrictions were applied. Only full reports of studies were included.

Study designs of evaluations included in the review

The inclusion criteria for study design were not specified. Case reports and case series were excluded. The majority of the included studies were diagnostic cohorts; one diagnostic case-control study was included.

Specific interventions included in the review

Studies of any provocative test of the neck for diagnosing cervical radiculopathy were eligible for inclusion. A variety of tests were evaluated in the included studies: shoulder abduction test, Spurling's test, upper limb tension test (ULTT), traction/neck distraction test and Valsalva manoeuvre.

Reference standard test against which the new test was compared

Studies that compared the diagnostic test with a reference standard such as electromyography (EMG), plain film or other imaging test (e.g. magnetic resonance imaging, computed tomography, myelography) were eligible for inclusion. The majority of the included studies used either EMG or myelography as the reference standard. Details of the diagnostic criteria associated with these tests were reported or referenced.

Participants included in the review

Studies of patients with suspected cervical radiculopathy were eligible for inclusion. Where reported, the mean age ranged from 19 to 45 years and the percentage of female participants from 21 to 62%.

Outcomes assessed in the review

The included studies were required to report the sensitivity and specificity or sufficient data to enable their calculation.

How were decisions on the relevance of primary studies made?

Two reviewers independently screened titles and abstracts to identify studies for inclusion. Any disagreements were resolved by consultation with a third reviewer.

The assessment of methodological quality was based upon theQuality Assessment of Diagnostic Accuracy Studies (QUADAS) tool; the QUADAS items relating to partial verification bias (reference standard not applied to all participants) and incorporation bias (index test forms part of the reference standard) were not used as they were not felt to be relevant to this study. Two independent reviewers conducted the assessment, blinded to each other's assessments, and any disagreements were resolved by consensus. Agreement between the reviewers was quantified using an unweighted Cohen's kappa.

Two reviewers independently extracted the data using apre-developed data extraction form. The sensitivity and specificity, together with their 95% confidence intervals (CIs), were extracted or calculated for each test in each included study.

How were the studies combined?

The limited data available for each test and clinical heterogeneity between the studies precluded meta-analysis. The studies were therefore combined in a narrative.

How were differences between studies investigated?

Differences between the studies were discussed in the text. The results of the assessment of methodological quality were tabulated and accuracy data were presented stratified by test, with variations in the testing procedure summarised.

Six studies reporting a total of 16 diagnostic accuracy data sets were included. The studies included a total of 713 participants.

In terms of methodological quality, no study used the optimal reference standard (EMG and imaging combined) and only one was conducted in a primary care setting. The majority of the included studies (5 out of 6) were judged susceptible to disease progression bias and/or spectrum bias. Review bias, caused by the results of the reference standard being available to those interpreting the index text, or vice versa, was a concern for 3 of the 6 studies.

Shoulder abduction test: the sensitivity ranged from 0.17 (specificity 0.92) to 0.78 (specificity 0.75) and the specificity from 0.75 (sensitivity 0.78) to 0.92 (sensitivity 0.17), based on 3 studies.

Spurling's test: the sensitivity ranged from 0.30 (specificity 0.93) to 1.00 (specificity 0.94) and the specificity from 0.74 (sensitivity 0.50) to 1.00 (sensitivity 0.90), based on 4 studies and 7 data sets.

ULTT: the sensitivity ranged from 0.72 (specificity 0.33) to 0.97 (specificity 0.22) and the specificity from 0.11 (sensitivity 0.83) to 0.33 (sensitivity 0.72), based on 2 studies and 3 data sets.

Traction/neck distraction test: the specificity ranged from 0.90 to 0.97, based on 2 studies, with a sensitivity of 0.44 in both cases.

Valsalva manoeuvre: 1 study reported a sensitivity of 0.22 and a specificity of 0.94.

Where these are consistent with clinical history and examination, a positive Spurling's test, traction/neck distraction test and Valsalva manoeuvre may suggest cervical radiculopathy while a negative ULTT may rule it out. However, the paucity of data, between-study heterogeneity and poor methodological quality of the studies preclude firm conclusions on the usefulness of these tests, particularly in the primary care setting.

The review addressed a clearly stated research question, which was defined by appropriate inclusion criteria. The literature search involved a variety of sources and the full search strategy was reported; retrieval of the available studies was likely to have been good. The review process included appropriate measures to minimise error and bias and these were reported clearly. The methodological quality of the included studies was assessed using an appropriate tool, and the results of this assessment were reported in full and considered in the authors' interpretation of the available accuracy data.

Relevant details of the individual studies were reported where available. The narrative synthesis was appropriate given the degree of clinical heterogeneity between the studies. In general, the authors' conclusions were appropriately cautious given the limitations of the available data. Their statements concerning the potential clinical applications of the specified tests are consistent with the reported results of individual studies. However, no data were presented to support the implication that a combination of three positive tests may be useful to rule-in disease; reported specificities were high for each of these tests, but there were no data concerning their combined performance.

Practice: The authors state that, where these are consistent with clinical history and examination, a positive Spurling's test, traction/neck distraction test and Valsalva manoeuvre may suggest cervical radiculopathy while a negative ULTT may rule it out.

Research: Future diagnostic studies should consider adequacy of sample size and use a composite reference standard comprising both advanced imaging and electrodiagnostic testing.

Netherlands Chiropractic Association; Netherlands Association for Manual Therapies.

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.