08/12/2025
Just published 🔥
𝗡𝗲𝘂𝗿𝗼𝗹𝗼𝗴𝗶𝗰𝗮𝗹 𝗘𝘅𝗮𝗺𝗶𝗻𝗮𝘁𝗶𝗼𝗻 𝗳𝗼𝗿 𝗖𝗲𝗿𝘃𝗶𝗰𝗮𝗹 𝗥𝗮𝗱𝗶𝗰𝘂𝗹𝗼𝗽𝗮𝘁𝗵𝘆: 𝗔 𝗦𝗰𝗼𝗽𝗶𝗻𝗴
Cervical radiculopathy is a prevalent neuromusculoskeletal disorder characterized by segmental neurological deficits due to impaired conduction in one or more cervical nerve roots. Classical epidemiological studies have reported incidence rates between 0.63 and 5.8 per 1,000 people, with variability influenced by diagnostic criteria, geographical characteristics, and occupational factors (https://pubmed.ncbi.nlm.nih.gov/32710604/; Schmid et al., 2018). Despite its frequency in clinical practice, diagnostic approaches remain inconsistent. Many clinical guidelines and research studies continue to emphasize radicular pain distribution rather than the loss-of-function signs (https://pubmed.ncbi.nlm.nih.gov/22531897/, https://pubmed.ncbi.nlm.nih.gov/28838857/) emphasized by the International Association for the Study of Pain (IASP), which defines radiculopathy as sensory and/or motor deficit caused by impaired axonal conduction (https://pubmed.ncbi.nlm.nih.gov/37235637/).
Previous reviews have predominantly focused on provocative tests or neurodynamic assessments. Both are designed to detect predominantly gain of nerve function, not loss of function and is therefore incompatible with the IASP definition.
Bedside neurological examination (BNE) comprising sensory, motor, and tendon reflex testing—provides the only direct clinical evaluation of nerve-root function loss.
📘 A brand-new scoping review by Yousif et al. (https://pubmed.ncbi.nlm.nih.gov/40188056/) aimed to map the literature regarding the diagnostic accuracy, components, and performance of the bedside neurological examination (BNE) for cervical radiculopathy (CR).
📊 𝗞𝗲𝘆 𝗙𝗶𝗻𝗱𝗶𝗻𝗴𝘀
From an initial 12,365 records, six cross-sectional studies met the inclusion criteria. These studies compared the BNE to either electrodiagnostic tests (Needle EMG and NCS) or Magnetic Resonance Imaging (MRI).
𝗗𝗶𝗮𝗴𝗻𝗼𝘀𝘁𝗶𝗰 𝗔𝗰𝗰𝘂𝗿𝗮𝗰𝘆 𝗼𝗳 𝗕𝗡𝗘 𝗖𝗼𝗺𝗽𝗼𝗻𝗲𝗻𝘁𝘀
✅ 𝗧𝗲𝗻𝗱𝗼𝗻 𝗥𝗲𝗳𝗹𝗲𝘅𝗲𝘀
Tendon reflex deficits (most commonly biceps, brachioradialis, and triceps) consistently demonstrated high specificity, ranging from 81% to 99%, depending on the reference standard. Sensitivity, however, was uniformly low, typically between 21% and 28% when compared with electrodiagnostic testing, although one MRI-based study reported a higher sensitivity of 67%. Positive likelihood ratios ranged widely, from 1.38 to 10, with the highest values seen when reflex loss was matched to a specific nerve-root level. Negative likelihood ratios were poor (around 0.80–0.95), indicating that a normal reflex does not rule out radiculopathy.
✅ 𝗦𝗼𝗺𝗮𝘁𝗼𝘀𝗲𝗻𝘀𝗼𝗿𝘆 𝗧𝗲𝘀𝘁𝗶𝗻𝗴
Sensory testing—primarily using light touch or pinprick across dermatomes—showed the lowest sensitivity of all BNE components. Sensitivity commonly fell between 25% and 52%, even when combining modalities. Specificity ranged from 46% to 89%, making sensory loss only modestly helpful for diagnostic confirmation. Positive likelihood ratios were generally low, between 0.69 and 2.27, indicating minimal change in post-test probability. Negative likelihood ratios hovered around 0.78–1.35, reinforcing the limited value of normal sensation for excluding radiculopathy.
✅ 𝗠𝘂𝘀𝗰𝗹𝗲 𝗦𝘁𝗿𝗲𝗻𝗴𝘁𝗵 𝗧𝗲𝘀𝘁𝗶𝗻𝗴
Myotomal strength testing demonstrated moderate sensitivity when compared with electrodiagnostic studies (typically 54% to 73%) and higher specificity, often between 61% and 93%. When MRI served as the reference standard, sensitivity varied more widely (from 30% to 81%), with specificity around 72%. Positive likelihood ratios ranged from 1.05 to 7.71, with the highest values associated with strong, focal weakness in a representative myotome (e.g., biceps or triceps). Negative likelihood ratios were consistently above 0.40, indicating only limited rule-out capacity.
✅ 𝗖𝗼𝗺𝗯𝗶𝗻𝗲𝗱 𝗕𝗡𝗘 𝗖𝗼𝗺𝗽𝗼𝗻𝗲𝗻𝘁𝘀
When multiple deficits were present—for example, concurrent sensory loss and reduced reflexes—specificity increased markedly, often reaching 97–99%, with positive likelihood ratios as high as 14–22. Sensitivity in these combinations, however, was very low (generally 7–22%), meaning that absence of combined deficits does little to exclude radiculopathy.
💡𝗢𝘃𝗲𝗿𝗮𝗹𝗹 𝗜𝗻𝘁𝗲𝗿𝗽𝗿𝗲𝘁𝗮𝘁𝗶𝗼𝗻
✏️ The diagnostic profile of BNE components demonstrates that deficits in tendon reflexes or muscle strength meaningfully increase the likelihood of cervical radiculopathy, particularly when they occur together or in anatomically congruent patterns. In contrast, normal findings—especially for sensory testing—do not substantially lower the probability of disease. Clinically, 𝗕𝗡𝗘 𝗶𝘀 𝘁𝗵𝗲𝗿𝗲𝗳𝗼𝗿𝗲 𝗯𝗲𝘀𝘁 𝘂𝘀𝗲𝗱 𝘁𝗼 𝗿𝘂𝗹𝗲 𝗶𝗻 𝗿𝗮𝘁𝗵𝗲𝗿 𝘁𝗵𝗮𝗻 𝘁𝗼 𝗿𝘂𝗹𝗲 𝗼𝘂𝘁 𝗰𝗲𝗿𝘃𝗶𝗰𝗮𝗹 𝗿𝗮𝗱𝗶𝗰𝘂𝗹𝗼𝗽𝗮𝘁𝗵𝘆.
✏️ The scoping review confirms the 𝗹𝗮𝗰𝗸 𝗼𝗳 𝗮 𝘂𝗻𝗶𝘃𝗲𝗿𝘀𝗮𝗹𝗹𝘆 𝗮𝗰𝗰𝗲𝗽𝘁𝗲𝗱 𝗰𝗿𝗶𝘁𝗲𝗿𝗶𝗮 for CR, the heterogeneity of diagnostic criteria, and the use of suboptimal reference standards (EMG/NCS: testing only large-myelinated fibers, i.e.,A-β and motor fibers and MRI: does not necessarily reflect neural function). The reporting of the BNE procedure itself was poor and vague.
✏️ Despite these limitations, the BNE is considered a 𝘃𝗶𝘁𝗮𝗹 𝗰𝗼𝗺𝗽𝗼𝗻𝗲𝗻𝘁 of the initial diagnostic workup for suspected radiculopathy.
✏️ Future research must establish a consensus on the operational definition of radiculopathy, its reference standard, and the optimal performance of the BNE to determine its full clinical utility.
📷 Illustration: Neurologic examination of the upper extremities. https://shop.elsevier.com/books/millers-review-of-orthopaedics/thompson/978-0-443-11214-0
