Table 1.
Summary of Included Studies with Evidence Grades.
| Author and Year | Study Design (Number of Patients) | Conclusion | OCEBM Score | MINORS Score |
|---|---|---|---|---|
| Pain referral patterns | ||||
| Feinstein et al (1954) | Prospective cohort study (5) | Injection of hypertonic saline into the paravertebral soft tissue at C3-6 produced referred pain to the shoulder. | 1 | 12 |
| Dwyer et al (1990) | Prospective cohort study (5) | Injection of contrast medium into the facet joints (C4-7) caused referred pain to the shoulder. | 1 | 14 |
| Grubb (2000) | Case series (173) | A review of results of a series of cervical discograms showed characteristic pain referred to the shoulder from C4-7. | 4 | 7 |
| Tanaka (2006) | Prospective cohort study (50) | Compression of cervical nerve roots can cause scapular pain particularly at C5-6. | 1 | 14 |
| Gerber (1998) | Prospective cohort study (19) | Hypertonic saline injected into the AC joint that caused referred pain to the lateral neck. | 1 | 13 |
| Gorski (2003) | Case series (34) | Patients with shoulder impingement had relief of neck pain after subacromial injection. | 4 | 8 |
| Clinical assessment | ||||
| Austin (2015) | Case series (54) | Sleep disturbance/pain reported in 86% of patients with rotator cuff tear. After repair only 34% continued to have sleep disturbance/pain. | 4 | 10 |
| Henderson (1983) | Case series (736) | Only 0.6% patients with cervical radiculopathy did not have an instance of arm pain. | 4 | 1 |
| Wainner (2003) | Blinded prospective diagnostic test (82) | Absence of biceps muscle stretch reflex has a sensitivity of 94% for cervical radiculopathy. | 1 | 24 |
| Aktas (2015) | Case report (1) | Lateral pectoral nerve entrapment mimicking C6 radiculopathy. | 4 | 1 |
| Tong (2002) | Cross-sectional study (255) | Spurling’s test has specificity of 93% and sensitivity of 30% for cervical radiculopathy. | 1 | 10 |
| Davidson (1981) | Case series (22) | 15 of 22 patients with cervical radiculopathy had relief of symptoms with abduction of the shoulder. | 4 | 1 |
| Viikari-Juntura (1989) | Case series (43) | The specificity of Spurling’s test, shoulder abduction sign, and the axial manual traction test for radiculopathy were all 100%. However, the sensitivities were low, 28%, 26%, and 31%, respectively. | 4 | 12 |
| Caliş (2000) | Prospective cohort study (120) | Compared patients with impingement to patients without impingement. The tests with the highest specificity were the drop arm test (97.2%) and the painful arc test (80.5). | 2 | 17 |
| Gumina (2013) | Prospective cohort study (1567) | Compared patient with cervical radiculopathy to healthy controls. The arm squeeze test had a specificity of 91% and a sensitivity of 96%. | 1 | 21 |
| Costandi (2015) | Retrospective case series (64) | 92% of patients who reported >50% pain relief after cervical transforaminal epidural steroid injection benefited from cervical surgery. | 4 | 10 |
| Anderberg (2006) | Prospective cohort study (30) | 18 of 22 patients with positive cervical transforaminal epidural steroid injection had good/excellent results with either ACDF or formal series of injections. | 1 | 14 |
| Lim (2005) | Prospective cohort study (101) | Patients with positive diagnostic subacromial injection had better improvement following subacromial decompression compared to those with a negative result. | 1 | 18 |
| Oh (2010) | Prospective cohort study (153) | Positive modified impingement test was associated with significant improvement following rotator cuff repair. | 2 | 13 |
| Concomitant/masquerading shoulder and neck pathology | ||||
| Paul (2007) | Retrospective case-control study (96) | 50% of patient presenting with shoulder pain had MRI abnormality of cervical spine. | 3 | 23 |
| Sembrano (2013) | Case series (694) | 3.6% of patients presenting for shoulder pain will have neck pathology. | 4 | 12 |
| Roberson (2015) | Case series (1169) | 4% of patients with a chief complaint of shoulder pain ended up having isolated cervical radiculopathy. | 4 | 8 |
| Uppal (1995) | Case series (8) | 8 patients with glenoid cysts which presented with symptoms mimicking cervical radiculopathy. | 4 | 1 |
| Pheasant (2016) | Case series (2) | Subacromial impingement resulting from rotator cuff weakness caused by intermittent C5 root compression. | 4 | 1 |
| Cannon (2018) | Case series (191) | The total prevalence of a musculoskeletal disorder is 42% in those undergoing electrodiagnostic studies for suspected cervical radiculopathy. In patients with confirmed radiculopathy it is 29% | 4 | 10 |
| Date (1996) | Case series (33) | 24% of patients with impingement syndrome were positive on EMG/NCS for cervical radiculopathy. | 4 | 10 |
| Hawkins (1988) | Case series (13) | 13 patients treated with anterior cervical decompression and fusion and subacromial decompression. | 4 | 6 |
| Manifold (1999) | Case series (22) | 66% of patients with both rotator cuff tears and confirmed cervical radiculopathy have relief of neck pain. | 4 | 3 |
| Jo (2012) | Case series (96) | 15% cervical spondylosis patients were ultimately diagnosed with shoulder disorders and required treatment. | 4 | 11 |
| Causative neck and shoulder pathology | ||||
| Culham (1993) | Case series (91) | Scapular protraction increased as thoracic kyphosis increased. | 4 | 7 |
| Greenfield (1995) | Case series (60) | Forward head posture was increased in shoulder overuse patient’s vs healthy controls. | 4 | 15 |
| Theisen (2010) | Prospective cohort study (78) | Patients with subacromial outlet syndrome had reduced thoracic motion. | 1 | 21 |
| Kebaetse (1990) | Case series (34) | Thoracic spine position significantly affects scapular kinematics and strength during abduction. | 4 | 14 |
| Yamamoto (2015) | Case series (2015) | Postural abnormality was a significant predictor of asymptomatic and symptomatic rotator cuff tears. | 4 | 24 |
| Kentar (2017) | Ecological study (319) | Kyphotic posture was associated with a high level of rotator cuff tears in wheel chair users. | 4 | 21 |
| Helgadottir (2011) | Prospective cohort study (44) | Symptomatic patients with whiplash had reduced scapular upward rotation compared to healthy controls. | 1 | 19 |
| Gumina (2009) | Prospective cohort study (134) | Type III acromioclavicular joint dislocation predisposes to cervical hyperlordosis when compared to healthy patients. | 1 | 24 |
| Zhang (2015) | Retrospective case-control study (679 112) | The association between cervical spine and rotator cuff pathology is greater than lumbar spine and rotator cuff pathology. | 3 | 9 |
| Ochiai (2017) | Case series (341) | 46% of patients with massive rotator cuff tears have cervical spondylitic amyotrophy | 4 | 4 |
| Campbell (2016) | Case series (24) | Evaluated patients with cervical spinal cord injury. | 4 | 15 |
| Goutallier (1994) | Case series (63) | Fatty atrophy detected in the intact infraspinatus in the face of supraspinatus tears. | 4 | 12 |
| Mallon (2006) | Prospective cohort (8) | 100% of patients with massive rotator cuff tears in this study had evidence of denervation of the supraspinatus muscle. In patients in which repair was performed, there was recovery of the suprascapular nerve. | 1 | 15 |
| Costouros (2007) | Prospective cohort study (26) | 28% of patients with massive rotator cuff repairs had evidence of peripheral nerve injury including suprascapular neuropathy and cervical radiculopathy. | 1 | 9 |
Abbreviations: OCEBM, Oxford Center for Evidence Based Medicine; MINORS, Methodological Index for Nonrandomized Studies; AC, acromioclavicular; ACDF, anterior cervical discectomy and fusion; MRI, magnetic resonance imaging; EMG, electromyography; NCS, nerve conduction studies.