Cloward Sign… An Oldie but a Goodie

Pain is tricky and one of the areas it can be most difficult to deal with is the spine, more specifically the cervical spine. It’s tough to determine structures that may be producing a perception of pain in the neck, mid-back, or arm due to the more widespread and far-reaching quality of neck pain. Luckily, we have a good resource to help decipher cervical spine pain and presentations thanks to an American neurosurgeon, Dr. Ralph B. Cloward.

In 1959 Dr. Cloward published a paper that helped map pain produced by the cervical disc at different levels using discography. He classified pain into two general groups, discogenic pain based on location (anterior, anterio-lateral, posterior, postero-lateral) and neurogenic pain based on structures (nerve root, dura, spinal cord).

Dr. Cloward first stimulated the anterior cervical discs, centrally, followed by peripherally. When the disc was stimulated centrally, the pain was produced in the center of the thoracic spine between the shoulder blades from about C7 to T7. Disc stimulation antero-laterally produced pain along the superior and medial border of the scapula on the side stimulated. Antero-lateral referral patterns are as follows…

  • C3/C4 Disc: C7 spinous process and top of the shoulder
  • C4/C5 Disc: Region of the spine and superior angle of scapula
  • C5/C6 Disc: Center of the scapular border
  • C6/C7 Disc: Region of the inferior angle of the scapula



He then stimulated the posterior aspect of the cervical discs both centrally and peripherally. Stimulation of the posterior cervical disc, centrally, produced a more central pain sensation between the shoulder blades that fans out across the mid back to the shoulders. When there was a postero-lateral stimulation of the cervical disc the pain spread further down the arm but never passing the elbow. Postero-lateral referral patterns are as follows:

  • C4/C5 Disc: pain spreads out in a band from the base of the neck to the top of the shoulder on the side stimulated.
  • C5/C6 and C6/C7 Disc: pain experienced over the scapula, across the shoulder joint, and along the lateral or posterior regions of the upper arm as far as the elbow


Hope this helps untangle the difficulty in correctly diagnosing possible pain generating structures for the cervical spine. Just remember that this is one piece of this complex puzzle and there are more structures and assessments that will help you further make a more accurate diagnosis.

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