What is the diagnosis and treatment for a patient with neck pain, right shoulder pain radiating down the arm, numbness, and tingling in the middle finger, with a positive piling test?

Cervical Radiculopathy (C6-C7)

This patient has cervical radiculopathy, most likely affecting the C7 nerve root based on the middle finger distribution, and should be managed initially with conservative treatment including NSAIDs, physical therapy, and reassurance that 75-90% of cases resolve spontaneously. 1, 2

Diagnosis

The clinical presentation is classic for cervical radiculopathy:

• Neck pain with radiation down the arm in a dermatomal pattern is the hallmark of nerve root compression 1, 3
• Numbness and tingling radiating to the middle finger suggests C7 nerve root involvement, as this follows the C7 dermatome 2, 3
• Positive Spurling test (pain with head rotation to the affected side) confirms nerve root compression with high specificity 2
• Pain intensification with head turning to the right indicates mechanical compression of the nerve root that worsens with foraminal narrowing 3

The most common causes are cervical disc herniation or cervical spondylosis with osteophyte formation compressing the nerve root 3, 4.

Imaging Recommendations

Do not order immediate imaging for this patient unless red flags are present. 1, 2

• MRI of the cervical spine without contrast is the appropriate imaging study if imaging becomes necessary, as it is most sensitive for detecting disc herniation and nerve root compression 1, 2
• Imaging should be deferred for 4-6 weeks unless red flags develop, because most cases resolve with conservative treatment and early imaging often reveals incidental degenerative findings that don't correlate with symptoms 1, 2
• The American College of Radiology emphasizes that imaging in acute radiculopathy without red flags rarely changes initial management 5

Red Flags Requiring Urgent Imaging

• Progressive motor weakness or severe neurological deficits 1, 2
• Bilateral symptoms suggesting myelopathy 1
• New bladder or bowel dysfunction 1
• Loss of perineal sensation 1
• Constitutional symptoms (fever, weight loss, night sweats) suggesting infection or malignancy 1
• History of cancer or trauma 2

Initial Conservative Management

Begin a multimodal conservative treatment approach immediately:

Medications

• NSAIDs (ibuprofen, naproxen) for pain and inflammation 2, 4
• Muscle relaxants may help with associated muscle spasm 2
• Consider neuropathic pain medications (gabapentin, pregabalin) if radicular symptoms are prominent 4

Physical Therapy

• Strengthening and stretching exercises targeting cervical and periscapular muscles 2, 4
• Cervical traction may temporarily decompress nerve impingement 4
• Short-term cervical collar use (days, not weeks) for acute symptom relief only 4

Prognosis and Reassurance

• 75-90% of patients improve with nonoperative therapy regardless of specific treatment modality 1, 6
• Most cases are self-limited with spontaneous improvement over weeks to months 2, 6
• Reassure the patient that the favorable natural history supports conservative management 2, 4

Follow-Up and Escalation

Reassess at 4-6 weeks:

• If symptoms are resolving or stable, continue conservative management 2
• If symptoms persist or worsen after 4-6 weeks of conservative treatment, obtain MRI to identify pathology amenable to epidural steroid injections or surgery 2, 4
• Epidural steroid injections may be considered for persistent radicular pain but carry higher risks of serious complications 2
• Surgery is indicated for debilitating pain unresponsive to 4-6 weeks of conservative treatment, progressive neurological deficits, significant weakness, or myelopathy 7, 6
• Surgical outcomes for arm pain relief range from 80-90% with either anterior or posterior approaches 6

Common Pitfalls

• Avoid ordering MRI in the first 4-6 weeks unless red flags are present, as this leads to identification of incidental degenerative changes that don't correlate with symptoms and may drive unnecessary interventions 1, 2
• Do not use cervical collars for prolonged periods, as this can lead to muscle deconditioning 4
• Do not assume imaging findings correlate with symptoms, as degenerative changes are common in asymptomatic individuals over age 30 5