What are the diagnostic tests and treatment options for a male with no underlying comorbidities presenting with neck pain radiating to the upper back and neck spasms, suspected of having cervical radiculopathy?

Diagnosis and Management of Suspected Cervical Radiculopathy with Neck Spasms

Based on your patient's presentation of neck pain radiating to the upper back with neck spasms, the most likely diagnosis is cervical radiculopathy, and you should obtain an MRI of the cervical spine without contrast as the definitive diagnostic test if symptoms persist beyond 4-6 weeks or if red flags are present. 1

Most Likely Diagnosis

Cervical radiculopathy is the primary diagnosis to consider, characterized by neck pain with radiating symptoms due to nerve root compression or irritation, typically from disc herniation or degenerative spondylosis. 2 The addition of neck spasms is consistent with this diagnosis, as muscle spasm is one of the most common examination findings in cervical radiculopathy. 3

Key Clinical Features Supporting This Diagnosis:

• Neck pain radiating to the upper back fits the typical presentation of nerve root compression from herniated discs or osteophytes 4
• Neck spasms and painful neck movements are the most common physical findings 3
• Annual incidence is 83.2 per 100,000, making this a common cause of these symptoms 2, 4

Diagnostic Testing Algorithm

Initial Clinical Assessment (No Imaging Yet):

Perform these specific physical examination maneuvers:

• Spurling test (neck extension with lateral rotation and axial compression toward the symptomatic side) - highly specific for nerve root compression from herniated cervical disc 4, 3
• Shoulder abduction test (relief of symptoms with arm abduction) 3, 5
• Upper limb tension test 3
• Deep tendon reflexes, particularly triceps reflex (diminished reflexes are the most common neurologic finding) 3
• Check for motor weakness, sensory deficits in dermatomal distribution 2, 6

When to Order Imaging:

Do NOT order imaging initially if:

• Symptoms are acute (<4-6 weeks duration) 2
• No red flags are present 2, 1
• No history of trauma 3

Rationale: 75-90% of cervical radiculopathy cases resolve spontaneously with conservative treatment, and imaging in the acute phase identifies incidental degenerative findings in asymptomatic individuals over age 30 that don't correlate with symptoms and may drive unnecessary interventions. 2, 1, 4

Order MRI cervical spine WITHOUT contrast if:

• Symptoms persist beyond 4-6 weeks of conservative therapy 7, 3
• Any red flags are present (see below) 4
• Progressive or severe neurological deficits develop 6

MRI is the gold standard imaging modality because it is the most sensitive test for detecting soft tissue abnormalities including disc herniation, nerve root compression, and spinal cord pathology. 2, 1, 4

Critical Red Flags Requiring IMMEDIATE MRI:

• Progressive motor weakness or neurological deficits 7, 1
• Bilateral symptoms suggesting myelopathy 7, 1
• New bladder or bowel dysfunction 7, 1
• Loss of perineal sensation 7
• Symptoms affecting both upper AND lower extremities 7, 1
• Constitutional symptoms (fever, weight loss, night sweats) suggesting infection or malignancy 7, 4
• History of malignancy or immunosuppression 4
• History of IV drug use 4
• Intractable pain 4
• Vertebral body tenderness on palpation 4

Role of Other Imaging:

Plain radiographs (X-rays): Widely accessible and useful for diagnosing spondylosis, degenerative disc disease, and malalignment, but therapy is rarely altered by radiographic findings in the absence of red flags. 2

CT myelography: Not appropriate as first-line imaging. 2

Electrodiagnostic testing: Not needed if the diagnosis is clinically clear, but has utility when peripheral neuropathy is a likely alternate diagnosis. 3

Treatment Approach

Initial Conservative Management (First 4-6 Weeks):

Reassure the patient that 75-90% of cases resolve with nonoperative therapy. 1, 4, 8

Implement multimodal conservative treatment:

• Physical therapy with strengthening and stretching exercises 3, 5
• NSAIDs for pain control 3, 8
• Muscle relaxants for neck spasms 3
• Short-term cervical collar use for immobilization (brief period only) 8
• Cervical traction may temporarily decompress nerve impingement 8
• Massage therapy 3

Note on medications: Evidence for neuropathic pain medications (gabapentin, pregabalin, tricyclic antidepressants) is scant for cervical radicular pain specifically. 5

Interventional Options if Conservative Treatment Fails:

For acute/subacute cervical radicular pain (symptoms <3 months):

• Epidural corticosteroid injection using interlaminar approach may provide relief 5
• Caution: Epidural steroid injections have higher risks of serious complications 3

For chronic cervical radicular pain (symptoms >3 months):

• Efficacy of epidural corticosteroids is limited 5
• Pulsed radiofrequency treatment adjacent to the dorsal root ganglion may be considered 5

Surgical Referral Indications:

• Intractable or persistent pain despite 4-6 weeks of sufficient conservative management 6
• Severe or progressive neurological deficits 6
• MRI findings showing pathology amenable to surgical decompression 3

Common Pitfalls to Avoid

Do not order MRI in the first 4-6 weeks without red flags - this leads to identification of incidental degenerative findings that are present in 53.9% of adults aged 18-97 and don't correlate with symptoms, potentially driving unnecessary interventions. 7, 4

Do not overlook alternate diagnoses such as peripheral nerve entrapment (which can mimic radiculopathy), particularly if symptoms don't follow classic dermatomal patterns. 7, 6, 9

Do not use flexion/extension radiographs - they have limited value in degenerative disease. 2

Reassess at 4-6 weeks to determine if symptoms are resolving, stable, or progressing before escalating to advanced imaging or interventions. 7