From the Guidelines
The next step in managing this patient would be to obtain an MRI of the cervical spine to better evaluate the degenerative changes at C4-5 and C5-6 and assess for potential nerve compression. This is based on the evidence from the American College of Radiology, which suggests that MRI is the preferred method for evaluating the cervical spine in cases of suspected nerve root impingement 1. The patient's persistent numbness, tingliness, and pain in the arms, despite completing physical therapy and being on Amitriptyline 25mg, suggest cervical radiculopathy from nerve root compression at the degenerative levels.
While waiting for the MRI, the patient can continue taking Amitriptyline 25mg daily, and consider increasing the dose gradually to 50-75mg at bedtime if tolerated, as higher doses are often needed for neuropathic pain relief. Additionally, adding a first-line neuropathic pain medication such as gabapentin (starting at 300mg daily and titrating up to 300mg three times daily as tolerated) or pregabalin (starting at 75mg twice daily) would be appropriate.
The evidence also suggests that MRI is the modality of choice for assessment of the spinal cord and nerve roots, allowing evaluation of the cord for edema, abnormal signal and/or enhancement, mass and mass lesion, and compression 1. A referral to a spine specialist (neurosurgeon or orthopedic spine surgeon) is warranted given the persistent neurological symptoms despite conservative management with medication and completed physical therapy. The specialist can evaluate whether surgical intervention might be beneficial based on the MRI findings and clinical presentation.
Some key points to consider in managing this patient include:
- Avoiding activities that exacerbate symptoms
- Using over-the-counter NSAIDs like ibuprofen 400-600mg three times daily with food for breakthrough pain if not contraindicated
- Considering a referral to a spine specialist for further evaluation and potential surgical intervention
- Continuing to monitor the patient's symptoms and adjusting the treatment plan as needed to optimize pain relief and improve quality of life.
From the Research
Patient Presentation and History
- The patient has been experiencing numbness and tingliness in the arms for two consecutive days, with persistent pain and stiffness in the neck.
- The patient is currently taking Amitriptyline Hcl Tab (Elavil) 25Mg Tab QPM and has recently completed physical therapy (PT).
- A cervical spine X-ray from January 2025 showed evidence of underlying degenerative disease at C4-5 and C5-6, with straightening of the cervical lordosis and moderate disc space narrowing.
Diagnostic Considerations
- Cervical radiculopathy is a possible diagnosis, given the patient's symptoms and imaging findings 2.
- The patient's symptoms must correlate with pathology for a successful diagnosis, and an magnetic resonance imaging (MRI) or computed tomographic myelogram may be necessary to confirm the diagnosis 2.
Treatment Options
- Conservative treatment is recommended for at least 6 weeks, consisting of immobilization, anti-inflammatory medications, physical therapy, cervical traction, and epidural steroid injections 2.
- Surgical treatment may be considered for patients who are persistently symptomatic despite conservative treatment, or those who have a significant functional deficit 2.
- Physical therapy is the mainstay of management for cervicogenic headache, and surgical interventions for cervical degenerative disease may relief an associated headache 3.
Next Steps
- Consider ordering an MRI or computed tomographic myelogram to confirm the diagnosis and assess the extent of degenerative disease 2.
- Continue conservative treatment, including physical therapy and anti-inflammatory medications, and reassess the patient's symptoms and functional status after 6 weeks 2.
- If the patient's symptoms persist or worsen, consider referring to a specialist, such as an orthopedic surgeon or neurologist, to discuss surgical options 2.