REIDER PART 2
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326 Chaftłr 8_Cervical and Thoracic Spinc

helps the examiner identify the approximate level of involvement.

Upper Limb Tension Tests

A number of upper limb nerve tension tests have been described by authors including Elvey, Kennealy, and Butler. These are sometimes known as the straight-leg raising tests of the arm becausc they are analogous to the nerve root tension signs of the lower extremity, such as the Lasegue test, the slump test, and the femoral nerve stretch test. Like their lower extremity counterparts, these maneuvers aim to reproduce or exacerbate neurologically based symptoms by płacing tension on the cervical nerve roots and the associated peripheral nerves. As in the lower extremity tension tests, these maneuvers often produce some degree of symptoms in normal individuals, such as aching or stretching sensations. The patients response to the test is considered abnormal if the maneuver repro-duces the patient’s familiar pain, which usually radiates distal to the elbow.

Upper Limb Tension Test 1

The upper limb tension test 1 (ULTT1) is a series of maneuvers applied to the upper extremity to place tension on the C5, the C6, and the C7 nerve roots, and it is described as median nerve dominant because the median nerve is the peripheral nerve most stressed by these maneuvers. Thus, the test is not specific with regard to a given level, but indicates irritation or compression of any one, two, or three of the involved roots, all of which contribute to the median nerve. However, each portion of the maneuver should be done carefully and gently because considerable tension may be placed on sensitive nerve roots. Throughout the procedurę, the examiner maintains communication with the patient to determine whether radicular symptoms are reproduced and, if so, at what point in the test.

To perform this test on the patient’s right side, the patient is positioned in a relaxed supine position along the right edge of the examination table. The examiner stands next to the table at the patient s right side. The examiner s left hand then grasps the patienfs right hand securely and gently abducts the patients shoulder, allow-ing the patients arm to rest along the examiners right thigh. The examiner’s right hand is placed in contact with the superior aspect of the patients right shoulder and driven firmly against the examination table. This allows the examiner s right hand to serve as a post that prevents further elevation of the patienfs shoulder girdle (Fig. 8-43A). The patienfs shoulder is then abducted to about 110° (Fig. 8-43B). While maintaining this position, the examiner supinates the patienfs forearm and extends the patients wrist and Fingers (Fig. 8-43C). The next step is to externally rotate the patients shoulder to 90° (Fig. 8-43/9). Next, the patient’s elbow is slowly extended (Fig. 8-43E). Finally, the patient is asked to laterally bend the neck, first toward the shoulder being examined (Fig. 8-43f) and then away from it (Fig. 8-43 G). If nerve root tension is present, laterally bending the neck toward the side being tested should relieve the symptoms, whereas bending it away from the side being tested should exaccr-bate them. Optionally, an assistant may perform a straight-leg raise to further increase nerve root tension (Fig. 8-43H).

The ULTT1 maneuver produces a sensation of stretching or aching in the antecubital fossa in almost all subjects. This is not considered an abnormal response. Pain suggestive of true radicular involvement would radi-ate to the lateral deltoid and the midarm (C5), down the dorsal radial aspect of the forearm to involve the index fin-ger and the thumb (C6), or centrally down the forearm to involve the dorsum of the hand and the long finger (C7).

Upper Limb Tension Test 2

The upper limb tension test 2 (ULTT2) also tests for irritation of the C6 or C7 nerve roots. There are two variants of this test, one that is median nerve dominant and one that is radial nerve dominant. They are both pcrformed with the patient lying supine on the examination table. Median Nerve Dominant. To perform the median nerve dominant variation, the patient is positioned at an angle so that the scapula of the side being tested projects past the edge of the table. When the right side is being tested, the examiner stands at the head of the table with the exam-iners left thigh resting against the superior aspect of the patients right shoulder. The examiner’s left hand holds the patients right elbow and the examiner’s right hand holds the patienfs right wrist (Fig. 8-44A). In a controlled manner, the examiner carefully depresses the patients shoulder girdle with pressurc from the examiner s thigh (Fig. 8-44B). The patienfs shoulder is abducted about 10° so that the arm is elear of the table. While maintaining the shoulder depression, the examiner next extends the patients elbow (Fig. 8-44C). Then, the examiner uses both hands to externally rotate the patient’s upper limb at the shoulder (Fig. 8-44D). The examiner’$ right hand then grasps the patient’s fingers securely and uses them to extend the mctacarpophalangeal joints and dorsiflex the wrist (Fig. 8-44E). Abducting the patienfs shoulder to 90° while maintaining the shoulder depression further inereases nerve root tension (Fig. 8-44F). As in the ULTT1, the patienfs response is considered abnormal only if radicular pain is elicited.

Radial Nerve Dominant. The radial nerve dominant variant of the UITT2 begins in the same position. Again, the patient is positioned obliqucly on the table so that the shoulder to be examined extends past the edge of the table. The examiner’s left thigh is again used to depress the patienfs right shoulder, and the patienfs elbow is extended as it was for the ULTT1 (Fig. 8-45A). This time, the examiner’s hands are used to internally rotate the entire upper extremity at the shoulder (Fig. 8-45B).