Neurological examination for cervical radiculopathy: a scoping review

Key points

1. 01Only 6 cross-sectional studies met inclusion criteria, reflecting a major gap in the literature
2. 02All BNE components (reflexes, sensation, muscle strength) showed low sensitivity but generally high specificity compared to EMG/NCS or MRI
3. 03Reduced tendon reflexes were the most specific component; sensory testing was least specific
4. 04Combining BNE components increased specificity (up to 99%) but further reduced sensitivity
5. 05BNE procedures were poorly and inconsistently reported across studies, limiting comparability

How it was conducted

Design

Scoping review following Arksey and O'Malley framework and JBI methodology, reported using PRISMA-ScR

Search

PubMed, Embase, Scopus, CINAHL, DiTA from inception to January 23, 2024; plus grey literature and citation tracking

Included studies

6 cross-sectional studies, all in English

Population

Patients with confirmed or clinically suspected cervical radiculopathy

Index test

Bedside neurological examination components: tendon reflexes, somatosensation (light touch, pin prick), and muscle strength testing

Reference standards

Needle EMG and nerve conduction studies (4 studies, 67%) or MRI (2 studies, 33%)

What they found

• Tendon reflex testing vs. EMG/NCS: sensitivity 21-22% (95% CI 11-27%; -LR 0.80-0.84), specificity 94-97% (95% CI 92-99; +LR 3.5-7.33)
• Tendon reflex testing vs. MRI: sensitivity 28-67% (95% CI 18-40% to 43-85%), specificity 81% (95% CI 69-89%; +LR 1.38)
• Pin prick sensation vs. EMG/NCS: sensitivity 25-38% (-LR 0.84-1.35), specificity 46-89% (95% CI 0.83-0.95%; +LR 0.7-2.27)
• Light touch vs. MRI: sensitivity 42-52% (95% CI 30-54% to 30-74%); combined sensory (light touch + pin prick) sensitivity 67% (95% CI 43-85%); specificity 72% (95% CI 59-82%; +LR 1.42-1.56)
• Muscle strength testing vs. EMG/NCS: sensitivity 54-73% (95% CI 38-65% to NR; -LR 0.44-0.49), specificity 61-93% (95% CI 85-97%; +LR 1.87-7.71)
• Muscle strength testing vs. MRI: sensitivity 30-81% (95% CI 20-43% to 58-95%), specificity 72% (95% CI 60-82%; +LR 1.05)
• Combination of tendon reflex deficit + sensory loss vs. EMG/NCS: specificity 99% (95% CI 94-100%; +LR 14-22), sensitivity 9-21%
• Full BNE (all 3 components) vs. EMG/NCS: sensitivity 7-83% (95% CI NR to 52-98%; -LR 0.61-0.95), specificity 28-99% (95% CI 13-47% to 95-100%; +LR 1.15-14)
• Full BNE vs. MRI: sensitivity 91% (95% CI 70-99%)
• No studies reported on muscle atrophy inspection despite it being a BNE component

Limitations

• No gold standard reference test for cervical radiculopathy exists; EMG/NCS and MRI each have known limitations including inability to assess small nerve fibers (EMG) and detection of structural rather than functional nerve compromise (MRI)
• BNE procedures were poorly described in 50% of studies and key muscles, reflexes, and sensory tests were non-consistent across studies
• Only 6 studies were identified, with small sample sizes and significant heterogeneity preventing meta-analysis or firm conclusions
• Study participants were recruited with heterogeneous diagnostic criteria, some using arm pain as the CR criterion rather than the IASP definition of loss of nerve function

Why it matters

For patients

If your clinician finds abnormal reflexes, sensation, or muscle strength in a dermatomal pattern, a positive result meaningfully raises the likelihood of a pinched nerve in your neck, but a normal examination does not rule it out.

For clinicians

BNE components have high specificity for cervical radiculopathy (useful for confirming the diagnosis) but low sensitivity (a normal BNE cannot exclude CR); combining components further raises specificity but should be interpreted alongside the full clinical picture and valid reference tests.

For readers

This scoping review is the first to systematically map BNE accuracy for cervical radiculopathy and identifies critical gaps: standardized procedures, accepted diagnostic criteria, and a valid reference standard are all needed before firm clinical recommendations can be issued.