What is the appropriate management for a patient presenting with a 2-day history of paresthesia (abnormal sensation) and mild shooting pain in the left arm and hand, accompanied by chronic neck pain and tightness, with no prior history of similar symptoms?

Management of Unilateral Upper Extremity Paresthesia with Chronic Neck Pain

This patient requires urgent MRI of the cervical spine to evaluate for cervical radiculopathy or myelopathy, given the combination of unilateral arm paresthesia with shooting pain and chronic neck pain. 1

Initial Diagnostic Approach

Red Flag Assessment

• The presence of new-onset unilateral arm paresthesia with shooting pain in all digits, combined with chronic neck pain, strongly suggests cervical radiculopathy as the primary diagnosis. 1
• The "electric" or shooting quality of pain is characteristic of neuropathic pain seen in radiculopathy, helping differentiate this from peripheral nerve entrapment. 1
• While the patient denies upper or lower extremity weakness, the absence of motor symptoms does not exclude significant nerve root compression. 1

Critical Exclusions Required

• Rule out cervical myelopathy (spinal cord compression): Although symptoms are currently limited to the left arm, any progression to bilateral symptoms, lower extremity involvement, or bowel/bladder dysfunction would indicate urgent myelopathy requiring immediate intervention. 1
• Assess for thoracic outlet syndrome (TOS): The combination of chronic neck pain with arm and hand paresthesia affecting all digits could represent neurogenic TOS, particularly if symptoms worsen with arm positioning or overhead activities. 2
• Exclude stroke/TIA: Acute onset paresthesia (2 days) requires consideration of cerebrovascular causes, though the absence of facial involvement, speech changes, or other focal deficits makes this less likely. 2, 3

Recommended Imaging

Primary Imaging Modality

• MRI of the cervical spine without contrast is the preferred initial imaging study. 1, 4
• MRI is superior for evaluating soft tissue abnormalities, nerve root compression, disc herniation, and spinal cord pathology that may be contributing to symptoms. 4
• The chronic neck pain history suggests underlying degenerative disease (likely C5-C6 or C6-C7 levels based on symptom distribution), which MRI will definitively characterize. 1, 4

Additional Imaging Considerations

• If MRI demonstrates cervical pathology but symptoms seem disproportionate or atypical, consider MRI of the thoracic outlet region to evaluate for TOS, particularly if there is evidence of brachial plexus compression. 2
• Plain radiographs are insufficient for complete evaluation given the acute neurological symptoms, as degenerative changes are common in asymptomatic individuals and correlate poorly with symptoms. 4

Physical Examination Priorities

Neurological Examination

• Test muscle stretch reflexes bilaterally (biceps, brachioradialis, triceps) to localize the affected nerve root level; asymmetric reflexes provide localizing value. 1
• Assess dermatomal sensory distribution to determine which cervical nerve root is affected (C6 affects thumb/index finger, C7 affects middle finger, C8 affects ring/small fingers). 1
• Evaluate for motor weakness in specific muscle groups: C5 (deltoid), C6 (biceps, wrist extensors), C7 (triceps, wrist flexors), C8 (finger flexors, intrinsic hand muscles). 1
• Perform Spurling's test (neck extension with rotation and axial compression toward the symptomatic side) to reproduce radicular symptoms. 1

Vascular and TOS Assessment

• Check bilateral upper extremity blood pressures to assess for subclavian artery stenosis, which can cause arm paresthesia and is associated with subclavian steal syndrome. 2
• Auscultate for supraclavicular or infraclavicular bruits that may indicate vascular TOS. 2
• Perform provocative maneuvers (Adson's test, Wright's test, Roos test) if TOS is suspected, though these have limited specificity. 2

Myelopathy Screening

• Test for upper motor neuron signs: Hoffmann's sign, hyperreflexia, clonus, Babinski sign. 1
• Assess gait and coordination to detect subtle myelopathic changes. 1
• Evaluate for bowel/bladder dysfunction through careful history. 1

Laboratory Evaluation

Initial Laboratory Testing

• Complete blood count to assess for infection, anemia, or hematologic disorders. 5
• Comprehensive metabolic panel including glucose to evaluate for diabetes mellitus, the most common cause of peripheral neuropathy. 5
• Vitamin B12 level as deficiency can cause paresthesias. 5, 6
• Thyroid-stimulating hormone to exclude thyroid dysfunction. 5
• Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) to assess for inflammatory or infectious processes, particularly given the acute onset. 4

Additional Testing if Initial Workup Negative

• Serum protein electrophoresis with immunofixation if monoclonal gammopathy is suspected. 5
• Hemoglobin A1c for diabetes screening if fasting glucose is borderline. 5

Immediate Management

Conservative Treatment Initiation

• Prescribe NSAIDs (if not contraindicated) for pain control and anti-inflammatory effect. 4
• Recommend activity modification: Avoid neck positions that exacerbate symptoms, particularly prolonged neck extension or rotation. 4
• Consider short-term cervical collar use (soft collar for comfort, not rigid immobilization) if symptoms are severe, though prolonged use should be avoided. 4

Pain Management

• For neuropathic pain, consider gabapentinoids (gabapentin 300-900mg three times daily or pregabalin 75-150mg twice daily) or antidepressants (duloxetine 30-60mg daily) if NSAIDs are insufficient. 5
• Avoid opioids for initial management given the chronic nature of symptoms and lack of evidence for long-term benefit in radiculopathy. 5

Urgent Referral Indications

Neurosurgery/Spine Surgery Consultation

• Progressive neurological deficits (worsening weakness, sensory loss, or pain despite conservative management). 1
• Signs of myelopathy (bilateral symptoms, lower extremity involvement, gait disturbance, bowel/bladder dysfunction). 1
• Severe, intractable pain unresponsive to conservative management. 1

Neurology Consultation

• Atypical presentation that doesn't fit a clear radicular pattern. 1
• Concern for alternative diagnoses such as multiple sclerosis, Guillain-Barré syndrome, or other neurological disorders. 2, 1
• Need for electrodiagnostic studies (EMG/NCS) if diagnosis remains unclear after imaging. 5

Vascular Surgery Consultation

• Suspected TOS with vascular compromise (asymmetric blood pressures >20mmHg difference, vascular bruits, signs of arterial insufficiency). 2

Follow-Up Plan

Short-Term Follow-Up (Within 1 Week)

• Review MRI results and adjust management accordingly. 1, 4
• Reassess neurological examination to detect any progression of symptoms. 1
• If MRI shows significant nerve root compression without myelopathy, initiate physical therapy focused on cervical traction, postural correction, and strengthening exercises. 4

Medium-Term Follow-Up (2-4 Weeks)

• If conservative management is pursued, reassess symptoms to determine response to treatment. 4
• Repeat inflammatory markers (ESR/CRP) if initially elevated to monitor for resolution. 4
• Consider referral to pain management if symptoms persist despite optimal medical management. 5

Common Pitfalls to Avoid

• Do not assume degenerative changes on imaging correlate with symptoms: Cervical spondylosis is common in asymptomatic individuals; clinical correlation is essential. 4
• Do not delay imaging in the presence of red flags: Acute onset neurological symptoms with chronic neck pain warrant urgent evaluation. 1, 4
• Do not overlook bilateral symptoms or lower extremity involvement: These indicate possible myelopathy requiring urgent surgical evaluation. 1
• Do not attribute all paresthesias to peripheral neuropathy: Central causes (stroke, myelopathy) must be excluded first. 7, 3
• Do not miss subclavian steal syndrome: Check bilateral blood pressures in all patients with arm paresthesia and neck pain. 2