Workup for Left-Sided Cervical Radiculopathy (2 Months Duration)
For a 2-month history of left-sided cervical radiculopathy, obtain MRI of the cervical spine without contrast as your primary imaging study 1.
Clinical Assessment First
Before imaging, perform a focused evaluation looking for:
- "Red flag" symptoms that would escalate urgency: fever, weight loss, immunosuppression, IV drug use history, coagulopathy, or elevated inflammatory markers (WBC, ESR, CRP) 1
- Spurling's test (high specificity 0.89-1.00 for cervical radiculopathy when positive) 2, 3
- Specific motor deficits: Document weakness patterns, particularly shoulder abduction and elbow flexion strength
- Dermatomal sensory changes corresponding to suspected nerve root level
- Reflex abnormalities at affected level
The physical examination has diagnostic value: Spurling's test, when positive alongside consistent history, strongly suggests cervical radiculopathy, while a negative upper limb tension test (ULTT) can help rule it out 3.
Imaging Algorithm
Primary Imaging: MRI Cervical Spine Without Contrast
MRI without contrast is the single most appropriate initial imaging study 1. Here's why:
- MRI correctly predicted 88% of surgical lesions in cervical radiculopathy versus 81% for CT myelography 1
- Superior for detecting soft tissue abnormalities, disc herniations, and nerve root compression 1, 4
- High spatial resolution for visualizing neural structures 1
Important caveat: MRI frequently shows abnormalities in asymptomatic patients, and detected abnormalities don't always correlate with clinical symptoms or examination levels 1. Your clinical findings must match the imaging findings.
Alternative Imaging Options
CT Myelography is appropriate if:
- Patient is claustrophobic and cannot tolerate MRI 1
- MRI is contraindicated (pacemaker, certain implants)
- MRI findings are equivocal but clinical suspicion remains high
CT myelography offers higher spatial resolution than MRI and excellent depiction of nerve roots, though it's invasive 1.
Plain radiographs are not recommended as initial imaging for established radiculopathy at 2 months 1.
CT without contrast has limited utility—it shows bony structures well but is less sensitive for nerve root compression from disc herniation compared to MRI 1.
Electrodiagnostic Studies
Consider EMG/nerve conduction studies within 4-6 weeks of presentation when:
- Severe focal motor weakness is present (particularly C5 with profound shoulder abduction/elbow flexion weakness) 5
- MRI findings are equivocal or don't match clinical picture 5
- Need to differentiate cervical radiculopathy from brachial plexopathy 5
EMG becomes particularly valuable when imaging is inconclusive, as it can be diagnostic even with equivocal MRI findings 5.
Common Pitfalls to Avoid
- Don't add IV contrast to MRI routinely—it adds no value for straightforward radiculopathy without red flags 1
- Don't order MRI without and with contrast as separate examination; the precontrast sequences alone are sufficient 1
- Don't rely solely on imaging—75-90% of cervical radiculopathy improves with conservative treatment regardless of imaging findings 6
- Don't assume imaging abnormalities explain symptoms—correlation with clinical examination is essential 1
Timeline Consideration
At 2 months, you're past the acute phase (<6 weeks) but most patients still improve with conservative management 6. The imaging workup helps:
- Confirm diagnosis
- Rule out serious pathology
- Guide treatment decisions if conservative management fails
- Establish baseline if surgical consultation becomes necessary
If significant functional deficit or myelopathy is present, expedite both imaging and specialist referral 6.