What is the management approach for a patient with neck pain, left upper limb weakness, preserved reflexes, and a cervical MRI showing no cord indentation but a compromised canal diameter?

Management of Cervical Radiculopathy with Upper Limb Weakness

The most appropriate management for this patient with neck pain, left upper limb weakness, preserved reflexes, and compromised cervical canal diameter is conservative management with physical therapy, NSAIDs, and gabapentin, with close monitoring for progression of neurological symptoms.

Clinical Assessment and Diagnosis

This patient presents with:

• Neck pain
• Left upper limb weakness
• Preserved reflexes
• Gradual progression over 2 months
• MRI showing compromised canal diameter but no cord indentation

This clinical picture is consistent with cervical radiculopathy without myelopathy. The preserved reflexes and absence of cord indentation on MRI suggest that despite the compromised canal diameter, there is not yet significant cord compression.

Management Algorithm

Step 1: Conservative Management (First-line approach)

• Physical therapy: Including range of motion exercises, strengthening of cervical and upper back muscles, and postural training 1
• Pharmacological therapy:
  • NSAIDs for inflammatory pain
  • Muscle relaxants for associated muscle spasm
  • Gabapentin starting at 300 mg once daily and gradually titrating up to 900 mg three times daily as needed for neuropathic pain 2, 3

Step 2: Close Monitoring

• Follow-up in 4-6 weeks to assess:
  • Progression of weakness
  • Development of new neurological symptoms
  • Response to conservative management

Step 3: Consider Advanced Imaging

• If symptoms worsen or fail to improve with conservative management:
  • Consider MRI with contrast to better evaluate soft tissue structures
  • CT may provide better evaluation of bony structures 4

Step 4: Surgical Intervention Criteria

Surgical intervention should be considered if:

• Progressive neurological deficit develops
• Significant symptoms persist despite 6-8 weeks of conservative management
• Development of myelopathic signs (hyperreflexia, Hoffmann sign, gait abnormality) 1

Evidence for Conservative Management

Gabapentin has shown efficacy in treating neuropathic pain conditions similar to cervical radiculopathy. In a randomized clinical trial comparing gabapentin to pregabalin for chronic sciatica, gabapentin demonstrated superior pain reduction with fewer adverse events 5. Starting at lower doses (300 mg daily) and gradually titrating up to 900 mg three times daily has been shown to be effective while minimizing side effects 3.

Surgical Considerations

Surgery is not indicated at this time given:

1. The absence of cord indentation on MRI
2. Preserved reflexes (no myelopathy)
3. Relatively short duration of symptoms (2 months)

According to current guidelines, surgical intervention should be reserved for patients with:

• Significant myelopathy
• Progressive neurological deficit
• Failure of conservative management 1

Important Caveats and Pitfalls

1. Don't miss myelopathy: Despite preserved reflexes, continue to monitor for development of myelopathic signs (Hoffmann sign, clonus, pathological reflexes)

2. Avoid prolonged opioid use: While short-term opioids may be considered for severe pain, long-term use should be avoided 1

3. Patient education: Advise on proper posture, ergonomics, and activities to avoid during recovery

4. Red flags requiring urgent reassessment:

   • Development of bladder/bowel dysfunction
   • Rapid progression of weakness
   • Development of bilateral symptoms
   • New gait abnormalities

By following this structured approach with early conservative management and vigilant monitoring, most patients with cervical radiculopathy can achieve significant improvement without requiring surgical intervention.