Bilateral Upper Limb Tingling Without Cervical Pain: Diagnostic Approach
This 40-year-old woman with bilateral upper limb tingling and no cervical pain requires MRI of the cervical spine without contrast as the initial imaging study to evaluate for cervical radiculopathy or myelopathy. 1, 2
Why MRI is the Appropriate First Step
The presence of bilateral upper extremity tingling represents radicular symptoms that distinguish this from simple mechanical neck pain, even in the absence of cervical pain itself. 1, 2 The American College of Radiology recommends MRI cervical spine without contrast as first-line imaging for patients with radiculopathy characterized by upper limb symptoms including tingling. 1
MRI correctly predicts 88% of cervical radiculopathy lesions and is the most sensitive imaging modality for assessing soft tissue abnormalities, including disc herniations, nerve root compression, and spinal cord pathology. 1, 2
Critical Red Flags Requiring Urgent Evaluation
Before ordering imaging, immediately assess for these concerning features that would necessitate emergency intervention: 1, 2
- Progressive motor weakness in either upper extremity
- Bilateral symptoms affecting BOTH upper AND lower extremities (suggesting cervical myelopathy rather than simple radiculopathy)
- New bladder or bowel dysfunction
- Loss of perineal sensation
- Gait disturbance or difficulty with fine motor tasks
The bilateral nature of her symptoms is particularly important—if she has any lower extremity involvement, this suggests myelopathy and requires urgent evaluation. 1, 2
Why Contrast is Not Needed
Contrast is unnecessary unless there is concern for infection, malignancy, or prior cervical surgery—none of which are suggested by this clinical presentation. 1, 2
Clinical Examination Priorities
While obtaining imaging, perform a focused neurological examination assessing: 3, 4
- Strength testing in individual upper limb muscles to identify patterns of weakness
- Sensory examination in dermatomal distributions
- Upper limb neurodynamic testing (ULNT), which shows substantial agreement with MRI findings in cervical radiculopathy and has 97% sensitivity when tests are combined 5
The neurological examination can reliably identify patterns suggesting focal neuropathies and has been validated to correlate with imaging findings. 4, 5
Expected Clinical Course and Management
Reassure the patient that 75-90% of cervical radiculopathy cases resolve with nonoperative therapy. 1, 2 Initial conservative management includes: 2
- Pain control with NSAIDs or acetaminophen
- Physical therapy with structured activity modification
- Short course of oral corticosteroids may be considered for acute severe radicular symptoms
Most cases resolve within 6-12 weeks, though 30-50% may have residual or recurrent symptoms up to 1 year. 2
Common Pitfalls to Avoid
Do not order plain radiographs as initial imaging—approximately 65% of asymptomatic patients aged 50-59 years show radiographic evidence of cervical spine degeneration regardless of symptoms, making radiographs non-specific and unhelpful for radiculopathy evaluation. 6
Do not assume bilateral symptoms are benign—bilateral upper extremity symptoms warrant the same thorough evaluation as unilateral symptoms, with particular attention to excluding myelopathy. 1, 2
Do not delay imaging if red flags are present—while most cervical radiculopathy is self-limiting, the presence of myelopathic features (bilateral symptoms with lower extremity involvement, bowel/bladder dysfunction) requires urgent intervention. 1, 2