What's the next step if cervical spine x-ray is normal but there's clinical concern for radiculopathy?

From the Guidelines

If a cervical spine x-ray is normal but there's clinical concern for radiculopathy, the next step should be ordering an MRI of the cervical spine. This is because MRI provides detailed visualization of soft tissues including nerve roots, intervertebral discs, and spinal cord that may not be visible on plain radiographs, as noted in the study by Brown et al 1. While waiting for the MRI, conservative management should be initiated, including:

• NSAIDs such as ibuprofen 400-800mg three times daily or naproxen 500mg twice daily for pain and inflammation
• Physical therapy focusing on cervical spine exercises
• Muscle relaxants like cyclobenzaprine 5-10mg at bedtime may be added for muscle spasms
• If pain is severe, a short course of oral steroids such as prednisone taper starting at 60mg daily and decreasing over 5-7 days might be considered. Radiculopathy often results from nerve root compression due to disc herniation, foraminal stenosis, or osteophyte formation, which are better evaluated with MRI 1. If MRI is contraindicated, a CT myelogram would be an alternative, as it may prove useful in diagnosing foraminal stenosis, bony lesions, and nerve root compression 1. Electromyography and nerve conduction studies may also be considered if symptoms persist despite normal imaging to confirm radiculopathy and identify the specific nerve roots involved.

From the Research

Next Steps for Cervical Radiculopathy

If a cervical spine x-ray is normal but there's clinical concern for radiculopathy, the following steps can be considered:

• Correlation with MRI can be considered to further evaluate the condition 2
• Nonoperative treatment options can be explored, including physical therapy, nonsteroidal anti-inflammatory drugs, muscle relaxants, and massage 2, 3, 4
• Epidural steroid injections may be helpful, but have higher risks of serious complications 2, 3
• A multimodal approach to treatment, including a combination of therapies, may benefit patients with cervical radiculopathy and associated neck pain 4
• Surgical treatment options, such as anterior cervical decompression and fusion, cervical disk arthroplasty, and posterior foraminotomy, may be considered for patients with persistent symptoms or significant functional deficits 3, 5

Diagnostic Considerations

• A thorough history and physical examination are essential for diagnosing cervical radiculopathy 3, 5
• Imaging modalities, such as MRI or computed tomographic myelogram, can confirm the diagnosis and identify pathology amenable to treatment 2, 3, 5
• Electrophysiological testing may be useful in confirming the diagnosis, especially when peripheral neuropathy is a likely alternate diagnosis 2

Treatment Outcomes

• Most patients with cervical radiculopathy will improve over time with nonoperative treatment, with 75%-90% achieving symptomatic improvement 3
• A step-wise approach to treatment, from conservative therapy to potential surgery, can help improve or resolve radicular pain syndromes and improve functional status and quality of life 6