Is ongoing neck pain radiating to the shoulder without relief in a patient with mild spinal canal stenosis and moderate left neuroforaminal stenosis at the C7-T1 level a reason to discuss with a neurosurgeon?

Should This Patient Be Referred to Neurosurgery?

Yes, this patient warrants neurosurgery consultation given the combination of moderate left neuroforaminal stenosis at C7-T1, persistent radicular symptoms radiating to the shoulder, and failure of conservative management. 1

Clinical Context and Rationale

This patient presents with cervical radiculopathy—neck pain radiating to the shoulder—which suggests C7 or C8 nerve root involvement given the anatomic location of moderate left neuroforaminal stenosis at C7-T1. 1, 2 The key decision point is whether conservative therapy has been adequately trialed and failed. 1

When Neurosurgical Referral Is Indicated

Referral to neurosurgery is appropriate when:

• Persistent symptoms beyond 6-8 weeks of conservative therapy despite appropriate treatment, which appears to be this patient's situation 1, 3
• Progressive neurological deficits including motor weakness, sensory changes, or gait disturbance 1, 3
• Severe intractable pain unresponsive to conservative measures 1, 3
• Presence of myelopathic signs suggesting spinal cord compression 3

The American College of Radiology emphasizes that while 75-90% of cervical radiculopathy cases resolve with conservative nonoperative therapy, the remaining 10-25% may require surgical intervention. 1, 2 This patient appears to fall into the latter category given the stated lack of relief.

Critical Assessment Before Referral

Red Flags Requiring Urgent Evaluation

Before routine neurosurgical referral, ensure the patient does not have red flag symptoms requiring immediate imaging and urgent consultation: 1, 3

• Constitutional symptoms (fever, unexplained weight loss, night sweats)
• History of malignancy or immunosuppression
• History of IV drug use
• Progressive neurological deficits or myelopathy
• Vertebral body tenderness on palpation

Confirm Radiculopathy Diagnosis

Verify the clinical diagnosis matches the imaging findings: 1, 3

• Document the specific dermatomal distribution of pain and any sensory/motor deficits
• Perform Spurling's test (highly specific for nerve root compression from herniated disc or foraminal stenosis) 1, 3
• Assess for myelopathic signs (hyperreflexia, Hoffman's sign, clonus, gait disturbance) that would indicate spinal cord compression requiring urgent evaluation 3

Imaging Considerations

If not already performed, MRI cervical spine without contrast should be obtained before neurosurgical consultation. 1, 3 MRI is the most sensitive imaging modality for detecting disc herniation, nerve root impingement, and excluding serious pathology such as infection or tumor. 1, 3 The existing report describes "moderate left neuroforaminal stenosis C7-T1," but MRI provides superior soft tissue detail compared to CT for surgical planning. 3

Common Pitfall to Avoid

Do not assume all degenerative changes on imaging are causative—spondylotic changes are present in 85% of asymptomatic individuals over 30 years of age. 3 The imaging findings must correlate with the clinical presentation. 3 However, in this case, the moderate neuroforaminal stenosis at C7-T1 with corresponding radicular symptoms suggests a clinically significant lesion.

Expected Surgical Outcomes

If the patient proceeds to surgical decompression, outcomes for relief of arm pain range from 80-90% with either anterior or posterior approaches. 2 Surgical decompression is indicated when nonsurgical treatment fails to relieve symptoms or if significant neurologic deficit exists. 2

Conservative Management Failure

The natural history of cervical radiculopathy suggests that patients with persistent disabling pain despite conservative therapy are candidates for surgery. 4 Unlike axial neck pain (which is best treated without surgery), radiculopathy that persists beyond appropriate conservative treatment warrants surgical consideration. 4

Bottom line: This patient has failed conservative management with persistent radicular symptoms and anatomically corresponding moderate neuroforaminal stenosis—this meets criteria for neurosurgical consultation. 1, 2