What is the appropriate diagnostic and management approach for a patient with chronic neck and upper back muscle spasm, deltoid area burning discomfort, finger numbness, and leg hyperreflexia?

Cervical Myelopathy with Radiculopathy: Urgent MRI Required

This patient requires urgent MRI of the cervical spine without contrast to evaluate for cervical myelopathy, as the combination of upper extremity radiculopathy (C8 distribution affecting fingers 4-5), deltoid burning (C5-C6), and leg hyperreflexia strongly suggests spinal cord compression—a condition that can lead to permanent neurological disability if not promptly diagnosed and treated. 1

Critical Red Flag Assessment

The presence of leg hyperreflexia in a patient with cervical symptoms is a pathognomonic sign of myelopathy indicating spinal cord involvement, not just nerve root compression. 1 This distinguishes this case from simple cervical radiculopathy and elevates urgency significantly.

Key Clinical Features Present:

• C8 radiculopathy pattern: Numbness of 4th and 5th fingers with increased typing errors suggests ulnar-sided sensory deficit 1
• C5-C6 involvement: Burning discomfort over deltoid region indicates additional cervical levels affected 1
• Upper motor neuron signs: Leg hyperreflexia indicates cord compression above the lumbar spine 1
• Chronic progressive course: Waxing and waning symptoms suggest intermittent compression with potential for acute deterioration 1

Immediate Diagnostic Approach

First-Line Imaging: MRI Cervical Spine Without Contrast

MRI is the most sensitive imaging modality for soft tissue abnormalities including spinal cord compression, disc herniation, and ligamentous pathology. 1 The presence of myelopathic signs (leg hyperreflexia) makes this imaging urgent rather than elective.

• Do not delay imaging when upper motor neuron signs are present, as this indicates spinal cord involvement requiring potential surgical decompression 1
• Contrast is not needed initially unless there is concern for infection, tumor, or inflammatory conditions 1
• MRI must be interpreted in conjunction with clinical findings, as asymptomatic cervical abnormalities are common in the general population 1

Electrodiagnostic Studies

Obtain EMG/nerve conduction studies to confirm the distribution and severity of nerve root involvement and exclude peripheral neuropathy or other mimics. 2, 3

• These studies alter clinical management in 55% of cases by either changing diagnosis or treatment plans 2
• NCS can quantify nerve conduction velocity and amplitude, distinguishing axonal from demyelinating processes 3
• EMG can detect denervation patterns consistent with radiculopathy and assess chronicity 3, 4

Differential Diagnosis Considerations

Rule Out Peripheral Neuropathy

The bilateral finger numbness (especially 4th-5th digits) could suggest ulnar neuropathy or polyneuropathy, but the presence of leg hyperreflexia makes peripheral neuropathy unlikely as the sole diagnosis, since peripheral nerve disease causes hyporeflexia, not hyperreflexia. 1, 4

Assess for Combined Pathology

Patients can have both cervical myelopathy AND peripheral neuropathy (e.g., from diabetes, HCV, or other systemic causes). 1 The burning quality of symptoms and sensory predominance warrant consideration of small fiber neuropathy as a contributing factor. 1

Management Algorithm

Conservative Management (Only if Mild and Non-Progressive)

If imaging shows mild stenosis without cord signal changes and symptoms are stable:

• Physical therapy focusing on cervical stabilization and posture 1
• Neuropathic pain medications (gabapentin or pregabalin) for burning dysesthesias 5
• Short-term muscle relaxants (cyclobenzaprine 5-10mg) for muscle spasm, used only for 2-3 weeks maximum 6
• Avoid cervical manipulation which can worsen cord compression 1

Urgent Neurosurgical Referral Indications

Refer immediately to spine surgery if any of the following are present:

• Progressive myelopathy (worsening leg hyperreflexia, gait instability, hand clumsiness) 1
• MRI showing spinal cord compression with T2 signal changes (myelomalacia) 1
• Severe or rapidly progressive motor weakness 1
• Bowel/bladder dysfunction suggesting cauda equina or conus involvement 7

Critical Pitfalls to Avoid

Do Not Assume This is Simple Radiculopathy

The presence of leg hyperreflexia transforms this from cervical radiculopathy (which is often self-limiting) to cervical myelopathy (which requires urgent evaluation and often surgical decompression). 1 Approximately 75-90% of cervical radiculopathy resolves with conservative management, but myelopathy does not. 1

Do Not Delay Imaging for "Trial of Conservative Therapy"

While cervical radiculopathy without myelopathy can be managed conservatively for 4-6 weeks before imaging, myelopathic signs warrant immediate MRI as delayed decompression can result in permanent neurological deficit. 1

Do Not Rely on Physical Examination Alone

Physical examination has limited accuracy for diagnosing cervical radiculopathy, and imaging correlation is essential before making treatment decisions. 1

Do Not Order CT as First-Line Imaging

CT is inferior to MRI for evaluating spinal cord compression and soft tissue pathology, though it may be complementary for assessing osseous structures like osteophytes. 1 MRI without contrast is the gold standard initial study. 1

Expected Clinical Course

If cervical myelopathy is confirmed and surgically decompressed promptly, neurological recovery is possible but often incomplete depending on duration and severity of compression. 1 Delayed treatment results in progressive irreversible spinal cord injury with permanent disability affecting both upper and lower extremities. 1