What is the proper referral for a patient experiencing nerve pain radiating to the upper back?

Proper Referral for Nerve Pain Radiating to Upper Back

For patients with nerve pain radiating to the upper back, the most appropriate initial referral is to a neurologist or pain management specialist for MRI evaluation of the brachial plexus, as this is likely a plexopathy requiring specialized imaging and treatment. 1

Understanding the Clinical Presentation

When evaluating nerve pain radiating to the upper back, it's important to distinguish between several possible conditions:

• Brachial plexopathy: Pain, dysesthesia, and/or burning sensation occurring in multiple peripheral nerve distributions in the upper extremity
• Radiculopathy: Pain radiating in a specific dermatomal distribution with possible sensory or motor deficits
• Nonspecific back pain: Pain primarily in the back without specific neurological findings

Key Diagnostic Features

• Brachial plexopathy signs: Pain in shoulder and arm with neuropathic character occurring in multiple peripheral nerve distributions, weakness, sensory loss, and flaccid loss of tendon reflexes 1
• Radicular pain signs: Pain radiating in a dermatomal distribution with possible sensory/motor deficits in a specific nerve root pattern 1

Diagnostic Approach and Referral Algorithm

1. For severe or progressive neurologic deficits:

   • Immediate referral to emergency department or neurosurgical consultation
   • Prompt MRI or CT is recommended 1

2. For suspected brachial plexopathy:

   • Referral to neurologist or pain management specialist
   • MRI of the brachial plexus (not routine neck/spine MRI) 1
   • Electrodiagnostic studies to confirm clinical diagnosis

3. For suspected radiculopathy with persistent symptoms:

   • Referral to spine specialist (neurosurgeon or orthopedic surgeon) if symptoms persist beyond 4 weeks despite conservative management 1
   • MRI is recommended only if patient is a potential candidate for surgery or epidural steroid injection 1

4. For nonspecific back pain:

   • Initial management by primary care with referral to physical therapy
   • Consider pain management referral if no improvement after 3 months of conservative treatment 1

Imaging Considerations

MRI acquisition for the brachial plexus differs significantly from routine neck or spine MRI:

• Should include orthogonal views through the oblique planes of the plexus
• T1-weighted, T2-weighted, fat-saturated T2-weighted sequences
• May include fat-saturated T1-weighted postcontrast sequences 1

Treatment Pathways Based on Referral

Neurologist/Pain Management Specialist

• Comprehensive evaluation of neuropathic pain
• Medication management (anticonvulsants, SNRIs, TCAs) 1
• Consideration of interventional procedures for refractory pain:
  • Transcutaneous electrical nerve stimulation (TENS)
  • Nerve blocks
  • Dorsal column stimulation 1, 2

Spine Specialist

• Evaluation for surgical intervention if appropriate
• Epidural steroid injections for radicular pain 1
• Timing: Severe radicular pain should be referred within 2 weeks; less severe within 3 months 1

Common Pitfalls to Avoid

1. Inappropriate imaging: Routine spine MRI without specific plexus protocols may miss plexopathy 1

2. Delayed referral: Patients with severe radicular pain or neurological deficits should be referred promptly rather than waiting for failed conservative management 1

3. Misdiagnosis: Approximately 33.5% of patients with chronic back pain have ≥3 characteristic signs of neuropathic pain that may be missed without proper screening 3

4. Unnecessary neurological consultation: For non-neurologic back pain, neurologist input may not significantly affect diagnosis or management 4

By following this referral algorithm based on clinical presentation, patients with nerve pain radiating to the upper back can receive appropriate specialized care that addresses the underlying pathology, whether it's plexopathy, radiculopathy, or another pain condition.