What is the workup for a patient with neck pain and numbness radiating down the arms?

Diagnostic Workup for Neck Pain with Radicular Symptoms

For patients with neck pain and numbness radiating down the arms, MRI is the preferred diagnostic imaging modality to evaluate cervical radiculopathy and rule out space-occupying lesions. 1

Initial Assessment

• History and examination focus points:

  • Distribution of symptoms (specific nerve root patterns)
  • Presence of neurological deficits (weakness, sensory changes)
  • Red flags for serious pathology:
    • Progressive neurological deficits
    • Signs of myelopathy
    • History of cancer
    • Fever or constitutional symptoms
    • Recent trauma
    • Age >50 years

• Neurological examination:

  • Motor strength in upper extremities
  • Sensory testing in dermatomes
  • Deep tendon reflexes
  • Specific nerve root compression tests
  • Signs of myelopathy (hyperreflexia, Hoffman's sign, clonus)

Diagnostic Imaging Algorithm

Step 1: Initial Imaging Decision

• For patients with radicular symptoms (numbness radiating down arms):

  • MRI is the preferred initial imaging modality 1
  • Should be performed within 24 months prior to any interventional treatment

• CT scan considerations:

  • Preferred for acute trauma cases
  • Better for bone detail visualization
  • Alternative when MRI is contraindicated 1

Step 2: Special Imaging Considerations

• Consider positional MRI in cases where symptoms are position-dependent

  • Imaging in the position that reproduces symptoms may increase diagnostic sensitivity 2
  • Standard recumbent MRI may underestimate pathology when the position takes stress off the spine

• CT myelography:

  • Consider when MRI is contraindicated
  • Useful for surgical planning 1

Clinical Pearls and Pitfalls

• Common pitfall: Treating neck pain without proper imaging when radicular symptoms are present

  • Radicular symptoms warrant advanced imaging to rule out space-occupying lesions 1

• Important caveat: Neck pain with radicular symptoms may occasionally represent serious underlying pathology

  • Case reports document unusual diagnoses including spinal cord compression from malignancy 3, 4
  • Cervical disc herniation with myelopathy 5
  • Bony exostosis causing cord compression 3

• Documentation tip: For insurance approval, clearly document:

  • Neurological signs and symptoms
  • Specific nerve root compression signs
  • Distribution of symptoms
  • Functional limitations
  • Failed conservative treatments 1

Treatment Considerations After Diagnosis

• Initial management typically includes:

  • Conservative measures for 4-6 weeks (NSAIDs, physical therapy)
  • For persistent symptoms, consider targeted epidural steroid injections
  • Surgical intervention for progressive neurological deficits or failure of conservative management after 6-8 weeks 1

• Warning: Delayed diagnosis and treatment of severe neurological deficits or serious underlying conditions are associated with poorer outcomes, emphasizing the importance of prompt and appropriate imaging 1