What is the best course of treatment for a 49-year-old male patient with chronic neck pain radiating to the left arm and causing tingling sensations in the left hand?

Management of Cervical Radiculopathy with Chronic Neck Pain and Arm Symptoms

Initial Diagnostic Approach

This patient has cervical radiculopathy based on the classic presentation of neck pain radiating to the arm with tingling, and MRI of the cervical spine without contrast is the appropriate initial imaging study. 1

Clinical Diagnosis

• The combination of neck pain radiating to the left arm with tingling in the left hand over 6 months represents cervical radiculopathy, characterized by nerve root compression or irritation 1
• Cervical radiculopathy has an annual incidence of 83 per 100,000 persons and frequently presents with neck and upper limb pain with varying degrees of sensory or motor deficits 1
• The radicular symptoms (arm radiation and hand tingling) distinguish this from simple mechanical neck pain and warrant advanced imaging 1

Imaging Recommendations

MRI cervical spine without IV contrast is the most appropriate initial imaging modality for this patient. 1

• MRI is the most sensitive imaging modality for assessing soft tissue abnormalities including disc herniations, nerve root compression, and spinal cord pathology 1
• In the presence of radiculopathy symptoms (arm pain and tingling), MRI is considered first-line imaging even though it would not be recommended for isolated neck pain without neurologic symptoms 1
• Contrast is not necessary unless there is concern for infection or malignancy, which are not suggested by this clinical presentation 1

Alternative Imaging Considerations

• Plain radiographs (5 views: AP, lateral, open-mouth, and both obliques) can be performed initially to screen for spondylosis and degenerative disc disease, but will not adequately evaluate nerve root compression 1, 2
• CT is not recommended as first-line imaging for radiculopathy as it provides inferior soft tissue detail compared to MRI 1
• CT myelography is reserved for patients who cannot undergo MRI or when MRI findings are equivocal 1, 2

Conservative Treatment Strategy

Most patients with cervical radiculopathy (75-90%) achieve symptomatic relief with nonoperative conservative therapy, making this the appropriate initial treatment approach. 1, 3

Multimodal Conservative Management

Medications

• NSAIDs (non-steroidal anti-inflammatory drugs) are effective for acute and chronic neck pain and should be first-line pharmacologic therapy 4
• Muscle relaxants provide benefit in acute neck pain associated with muscle spasm 4, 5
• Neuropathic pain medications may be considered given that nearly half of chronic neck pain patients have mixed neuropathic-nociceptive or predominantly neuropathic symptoms 4

Physical Interventions

• Exercise therapy has the strongest evidence among complementary treatments for neck pain 4, 5
• Physical therapy should be incorporated into the treatment plan 3
• Cervical collars may be used for short-term immobilization (not prolonged use) 3
• Cervical traction may provide temporary decompression of nerve root impingement 3

Additional Modalities with Supporting Evidence

• Massage has weaker but supportive evidence for neck pain 4
• Acupuncture has weaker evidence supporting its use in certain contexts 4
• Spinal manipulation has weaker evidence and should be used cautiously 4

Interventional Options if Conservative Treatment Fails

• Selective nerve root blocks can target specific nerve root pain, though evidence is limited 3
• Epidural steroid injections have conflicting evidence for cervical radiculopathy 5
• These interventions should be considered only after adequate trial of conservative therapy 3

Surgical Considerations

Surgery should be reserved for patients with persistent or progressive neurologic deficits despite conservative management, as surgery is more effective than conservative treatment only in the short term but not long term. 4, 5

Indications for Surgical Referral

• Progressive neurological deficits despite conservative treatment 6
• Persistent severe symptoms after 6-12 weeks of appropriate conservative therapy 5, 7
• Development of myelopathy (spinal cord compression) 7

Important Caveat

• Clinical observation and continued conservative management is a reasonable strategy before proceeding to surgery, as long-term outcomes are similar between surgical and nonsurgical approaches for most patients 4, 5

Red Flags Requiring Urgent Evaluation

While this patient's presentation appears consistent with typical cervical radiculopathy, monitor for:

• Progressive motor weakness or neurological deficits 6
• Bilateral symptoms suggesting myelopathy 6
• New bladder or bowel dysfunction 6
• Loss of perineal sensation 6
• Symptoms affecting both upper and lower extremities, which may indicate cervical myelopathy rather than simple radiculopathy 6

Prognosis

• Cervical radiculopathy is frequently self-limiting with 75-90% of patients achieving symptomatic relief with nonoperative therapy 1
• However, approximately 30-50% of patients with chronic neck pain will develop symptoms or disability lasting more than one year 1
• Most acute episodes resolve spontaneously, though more than one-third of affected people still have low-grade symptoms or recurrences after one year 4