What is the appropriate workup for a patient presenting with radiating pain to the neck and shoulder?

Workup for Radiating Pain to the Neck and Shoulder

Radiography of the shoulder and cervical spine is the most appropriate initial imaging study for patients presenting with radiating pain to the neck and shoulder, followed by MRI without contrast if radiographs are negative or inconclusive. 1

Initial Assessment

Step 1: Plain Radiographs

• Shoulder radiographs: Should include anteroposterior (AP) views in internal and external rotation, and axillary or scapula-Y view 2
• Cervical spine radiographs: Should include AP, lateral, and odontoid views
• Flexion-extension lateral views: May be considered if there is concern for instability 1

Step 2: Advanced Imaging Based on Radiograph Results

If Radiographs Are Normal:

• MRI without IV contrast is the next appropriate study for:
  • Nonlocalized shoulder pain 1
  • Suspected cervical radiculopathy 1, 3
  • Suspected nerve compression 4

If Radiographs Show Specific Findings:

• For humeral head/neck fracture: CT without IV contrast 1
• For scapular fracture: CT without IV contrast 1
• For Bankart or Hill-Sachs lesions: MRI shoulder without IV contrast or MR arthrography 1
• For suspected labral tear: MR arthrography, CT arthrography, or MRI shoulder without IV contrast 1

Differential Diagnosis Considerations

Cervical Radiculopathy

• Characterized by neck pain radiating to the shoulder and arm, often with sensory or motor deficits 3, 4
• Physical exam findings may include:
  • Spurling's test (positive: reproduces radicular symptoms when neck is extended and rotated toward the affected side) 5
  • Upper limb tension test (negative: helps rule out radiculopathy) 5
  • Decreased sensation, strength, or reflexes in the affected dermatome/myotome 6

Shoulder Pathology

• May present with similar symptoms to cervical pathology 7
• Key differentiating features:
  • Pain with specific shoulder movements (abduction, rotation)
  • Positive impingement signs
  • Localized tenderness over specific shoulder structures

Special Considerations

For Suspected Nerve Injury:

• MR neurography may be beneficial for peripheral nerve injuries, especially with 3-T imaging 1
• There is no role for MR arthrography, ultrasound, or FDG-PET/CT in suspected traumatic nerve injury 1

For Complex Regional Pain Syndrome (CRPS):

• Bone scintigraphy has high specificity and can be used to rule out CRPS 1
• However, it has low sensitivity compared to clinical diagnostic criteria 1

Common Pitfalls and Caveats

1. Overlapping symptoms: Cervical spine and shoulder pathologies often present with similar symptoms and can be difficult to differentiate 7

2. Incidental findings: MRI has a high rate of detected abnormalities in asymptomatic patients, so clinical correlation is essential 1

3. Premature advanced imaging: Avoid ordering MRI or CT as first-line examinations for neck pain without red flags or neurological symptoms 1

4. Incomplete radiographic series: Ensure proper views are obtained to avoid missing diagnoses 2

5. Delayed diagnosis of serious pathology: Be vigilant for "red flags" suggesting serious underlying conditions requiring urgent evaluation

By following this algorithmic approach, clinicians can efficiently diagnose the cause of radiating pain to the neck and shoulder, leading to appropriate treatment and improved patient outcomes.