What is the best course of treatment for an elderly patient with posterior neck pain radiating to the left shoulder, who is unable to lift their arm without pain?

Cervical Radiculopathy: Initial Conservative Management with Imaging if Refractory

This elderly patient most likely has cervical radiculopathy (C5 nerve root distribution based on shoulder pain and arm weakness), which should be managed initially with conservative treatment including NSAIDs, activity modification, and physical therapy, with MRI reserved for cases failing 6-12 weeks of conservative care or those with progressive neurologic deficits. 1, 2

Clinical Diagnosis

The presentation of posterior neck pain radiating to the shoulder with inability to lift the arm suggests C5 radiculopathy affecting shoulder abduction and potentially external rotation. 1, 2

Key diagnostic features include:

• Radiation pattern: Neck pain extending to shoulder and potentially down the lateral arm indicates nerve root compression rather than isolated shoulder pathology 2
• Motor weakness: Inability to lift the arm suggests deltoid weakness (C5 distribution) 1
• Age consideration: Elderly patients commonly develop cervical radiculopathy from degenerative spondylosis and foraminal stenosis 1

Differentiating from Shoulder Pathology

This must be distinguished from primary shoulder disorders:

• Shoulder impingement can present with neck pain near the superomedial scapula, but typically improves with subacromial injection 3
• Rotator cuff pathology causes pain with specific shoulder movements and positive impingement signs, not dermatomal radiation 4, 3
• Suprascapular neuropathy causes posterior shoulder pain and weakness but lacks neck pain as a primary feature 5

The key differentiator is that cervical radiculopathy produces dermatomal pain radiation and neurologic deficits following nerve root distributions, whereas shoulder pathology produces pain with specific shoulder movements and lacks dermatomal patterns. 6, 2

Initial Management Approach

Conservative Treatment (First-Line)

Acute cervical radiculopathy has a 75% rate of spontaneous improvement, making conservative management appropriate for most patients initially. 2

Specific interventions include:

• NSAIDs or acetaminophen for pain control 4
• Activity modification: Avoid positions that exacerbate symptoms, particularly neck extension and rotation 2
• Physical therapy: Gentle cervical traction, range of motion exercises, and strengthening once acute pain subsides 1
• Short-term cervical collar may provide temporary relief but should not be prolonged 1

Duration of Conservative Trial

Conservative management should be continued for 6-12 weeks before considering advanced imaging or surgical consultation. 1, 2

Imaging Strategy

When to Image

MRI of the cervical spine is indicated if:

• Symptoms persist beyond 6-12 weeks of conservative treatment 1
• Progressive neurologic deficits develop (worsening weakness, sensory loss) 1, 2
• Myelopathic signs appear (gait instability, bowel/bladder dysfunction, bilateral symptoms) 1

MRI without contrast is the preferred modality as it provides superior visualization of nerve root compression, disc herniation, and spinal cord pathology compared to CT. 1, 4

Imaging Pitfalls

Degenerative changes on MRI are extremely common in asymptomatic elderly patients and correlate poorly with symptoms. 1

• Spondylotic changes are present in most patients over 30 years and do not necessarily indicate the pain source 1
• Clinical correlation is essential—imaging findings must match the clinical presentation 1

Initial Radiographs Not Routinely Needed

Plain radiographs are not indicated for chronic neck pain without trauma, as they show only bony changes and do not visualize nerve roots or soft tissues. 1 Radiographs are reserved for trauma evaluation or when bony pathology (fracture, instability) is suspected. 7, 8

Surgical Consideration

Anterior cervical decompression is recommended if:

• Conservative treatment fails after 12 months 1
• Significant, progressive neurologic deficit exists 1, 2
• MRI confirms nerve root compression correlating with clinical findings 1

Surgical outcomes for arm pain relief range from 80-90% with either anterior or posterior approaches. 2 However, at 12 months, comparable clinical improvements can occur with physical therapy or surgery, though surgery provides faster initial relief of pain and weakness. 1

Red Flags Requiring Urgent Evaluation

Immediate imaging and specialist consultation are needed if:

• Myelopathic signs: Gait instability, bilateral symptoms, bowel/bladder dysfunction 1
• Progressive motor weakness: Rapidly worsening strength despite conservative care 1, 2
• Vascular symptoms: Though rare, vertebral artery dissection can present with neck pain and neurologic symptoms 9

Common Pitfalls

• Assuming all neck-shoulder pain is cervical spine pathology: Shoulder impingement can refer pain to the neck and may respond to subacromial injection 3
• Over-relying on imaging findings: Degenerative changes are ubiquitous in elderly patients and often asymptomatic 1
• Premature imaging: Most cases resolve with conservative care; early MRI may lead to unnecessary interventions 1, 2
• Ignoring progressive deficits: Worsening weakness or myelopathic signs require urgent evaluation regardless of symptom duration 1, 2