What is the most likely diagnosis for a patient with right shoulder and neck pain for 3 weeks without trauma, and arm pain reproduced when pushing down on their head while their neck is extended and leaning to the right?

Diagnosis: Cervical Disk Herniation

The most likely diagnosis is cervical disk herniation with radiculopathy, as the positive Spurling's test (neck extension with lateral flexion and axial compression reproducing arm pain) is highly specific for nerve root compression from a herniated cervical disk. 1

Clinical Reasoning

Pathognomonic Physical Examination Finding

• The described maneuver—pushing down on the head while the neck is extended and leaning toward the right—is the Spurling's test, which reproduces radicular symptoms by narrowing the neural foramen and compressing the affected nerve root 2
• This test is highly specific for cervical radiculopathy caused by disk herniation or foraminal stenosis, distinguishing it from other shoulder pathology 1
• The 3-week duration without trauma fits the typical presentation of spontaneous cervical disk herniation, which occurs in approximately 61% of cases without preceding injury 3

Why Not the Other Diagnoses

Rotator cuff tear:

• Would present with pain during shoulder abduction and external rotation, not with neck extension and axial loading 2
• Spurling's test would be negative; instead, positive Neer's or Hawkins-Kennedy tests would be expected
• Pain typically localizes to the shoulder without neck involvement 2

Shoulder impingement syndrome:

• Presents with pain during overhead activities and positive impingement signs (Neer's, Hawkins-Kennedy) 2
• Spurling's test would not reproduce symptoms in isolated shoulder pathology
• Neck extension with axial loading is not a provocative maneuver for shoulder impingement 2

Thoracic outlet syndrome:

• Would present with vascular or neurogenic symptoms during arm elevation or specific positions (Adson's test, Wright's test) 2
• Spurling's test is not characteristic of thoracic outlet syndrome
• Typically involves the lower trunk of the brachial plexus (C8-T1), causing symptoms in the medial arm and hand, not reproduced by cervical compression 2

Diagnostic Approach

Immediate Clinical Assessment

• Document the specific dermatomal distribution of pain and any associated sensory or motor deficits to localize the affected nerve root level 1, 2
• Screen for "red flags" including constitutional symptoms (fever, weight loss), history of malignancy, immunosuppression, or progressive neurological deficits that would require urgent imaging 1, 2
• Assess for myelopathic signs (gait disturbance, hyperreflexia, Hoffman's sign, clonus) that would indicate spinal cord compression requiring urgent surgical evaluation 1, 2

Imaging Strategy

• For acute cervical radiculopathy without red flags, imaging is not immediately required as most cases resolve with conservative management within 6-8 weeks 1, 4
• MRI cervical spine without contrast is the preferred imaging modality when imaging is indicated, as it is most sensitive for detecting disk herniation and nerve root impingement 1, 2
• Indications for MRI include: persistent symptoms beyond 6-8 weeks of conservative therapy, progressive neurological deficits, severe pain unresponsive to treatment, or presence of red flag symptoms 1, 2, 5

Management Algorithm

Conservative Treatment (First-Line)

• Initiate aggressive nonsurgical management including cervical traction, physical therapy with specific exercises, NSAIDs, and patient education 6, 4
• Studies demonstrate that 24 of 26 patients (92%) with cervical disk herniation and radiculopathy achieved successful outcomes without surgery using this approach 4
• Continue conservative therapy for 6-8 weeks before considering surgical consultation unless red flags or progressive deficits develop 5, 4

Surgical Indications

• Surgery is recommended for: clinico-radiological correlation with moderate neurological deficit appearing suddenly, progressive deficit under conservative treatment, or poorly controlled pain after 6-8 months of well-conducted conservative therapy 5
• Symptomatic cervical myelopathy is an absolute indication for surgical intervention to prevent irreversible spinal cord damage 5

Critical Pitfalls to Avoid

• Do not assume shoulder pathology based solely on "shoulder pain"—cervical radiculopathy commonly refers pain to the shoulder and arm, and the positive Spurling's test confirms cervical origin 2, 7
• Do not order imaging immediately in the absence of red flags—this leads to overdiagnosis of incidental degenerative changes that correlate poorly with symptoms 1, 4
• Do not interpret degenerative changes on imaging as causative without clinical correlation—spondylotic changes are present in 85% of asymptomatic individuals over 30 years 1
• Do not delay surgical referral if progressive neurological deficits develop—this represents a surgical emergency requiring urgent decompression 5