What is the appropriate diagnosis and management for a 51-year-old patient with hypertension, presenting with 5 months of tingling, numbness, and pain in the left shoulder and arm, with symptoms suggestive of cervical radiculopathy and suboptimal blood pressure control on Losartan 50mg daily?

Management of Cervical Radiculopathy with Suboptimal Hypertension Control

Immediate Recommendation

The diagnosis of cervical radiculopathy (likely C5-C7) is appropriate, and the planned cervical spine X-ray should be upgraded to MRI cervical spine without contrast, while the patient's blood pressure requires immediate intensification of therapy given the significantly elevated reading of 152/83 mmHg on monotherapy. 1, 2

---

Cervical Radiculopathy Diagnosis and Management

Diagnostic Accuracy

The clinical presentation strongly supports cervical radiculopathy:

• Dermatomal pain pattern radiating from shoulder to all fingers with 5-month duration indicates nerve root compression rather than primary shoulder pathology 2, 3
• Constant symptoms 2-3 times daily with severity 8/10 represents chronic radiculopathy requiring imaging 1, 4
• Reproduction of tingling on examination in the lateral shoulder/arm area confirms neuropathic origin 2, 5
• Normal shoulder examination with full ROM and no tenderness excludes primary shoulder pathology 2
• Bilateral involvement (right side occasionally affected) raises concern but does not indicate myelopathy given normal reflexes and motor strength 4

Critical Imaging Error in Current Plan

The planned cervical spine X-ray is inadequate and should be replaced with MRI cervical spine without contrast. 1, 2

Rationale for MRI over X-ray:

• The American College of Radiology recommends MRI as the preferred imaging modality for cervical radiculopathy, providing superior soft tissue visualization for detecting disc herniations and nerve root compression 1, 4
• X-rays cannot visualize discs or accurately evaluate nerve root impingement, making them insufficient for diagnosing the suspected pathology 1, 2
• With 5 months of persistent symptoms (chronic radiculopathy >12 weeks), this patient has already exceeded the conservative observation period where imaging can be deferred 1, 2
• MRI is most sensitive for detecting soft tissue abnormalities, disc herniation, nerve root impingement, and can exclude serious pathology like tumor or infection 1, 6

Red Flag Assessment

No urgent red flags are present, which is reassuring:

• No constitutional symptoms (fever, weight loss, night sweats) 1, 2
• No history of malignancy or immunosuppression 2, 6
• Normal inflammatory markers on recent bloodwork (normal FBC, LFTs) 1
• No myelopathic signs (normal reflexes, normal motor strength, normal sensation) 4, 5
• No progressive neurological deficits 1, 4

However, the 5-month duration with constant symptoms and severity 8/10 warrants imaging now rather than further delay 1, 2

Medication Management for Radiculopathy

The prescribed regimen is reasonable but requires clarification:

• Celecoxib 100mg BD is appropriate for inflammatory pain 7
• Amitriptyline 10mg nocte with titration to 75mg is evidence-based for neuropathic pain 7
• Multivitamin is unnecessary given normal B12, folate, and vitamin D levels on recent bloodwork 2

Conservative management success rate is 75-90% for cervical radiculopathy, so this approach is justified 6, 8, 9

Surgical Consideration Threshold

Surgery should be considered if:

• Persistent symptoms after 4-6 weeks of adequate conservative therapy (already met at 5 months) 4, 9
• Progressive neurological deficits develop 4, 5
• Severe pain unresponsive to multimodal treatment continues 1, 2

Surgical outcomes for arm pain relief range from 80-90% with either anterior or posterior approaches 9

---

Hypertension Management - Critical Priority

Blood Pressure Assessment

The current BP of 152/83 mmHg represents inadequate control and significantly elevated cardiovascular risk. 1

• Target BP should be <140/90 mmHg at minimum for this patient 1
• The systolic BP of 152 mmHg is 12 mmHg above target, representing substantial excess risk 1
• Patient refusal to intensify therapy is a critical clinical concern that requires immediate counseling 1

Cardiovascular Risk Context

This 51-year-old patient has:

• Established hypertension requiring treatment 1
• Suboptimal BP control on monotherapy (Losartan 50mg) 10
• No contraindications to dose escalation 10
• Slightly abnormal cholesterol adding to cardiovascular risk 1

Evidence-Based Dose Escalation

Losartan should be increased from 50mg to 100mg daily immediately. 10

FDA-approved dosing:

• Usual starting dose is 50mg once daily 10
• Dosage can be increased to maximum 100mg once daily as needed to control blood pressure 10
• Increasing from 50mg to 100mg provides additional placebo-adjusted BP reductions of approximately 15.5/9.2 mmHg 10

If BP remains >140/90 mmHg on Losartan 100mg:

• Add hydrochlorothiazide 12.5mg daily 10
• Can increase HCTZ to 25mg daily if needed 10
• This combination approach is supported by the LIFE study methodology 10

Patient Counseling Strategy

The patient's reluctance must be addressed with specific cardiovascular risk data:

• Uncontrolled hypertension increases risk of stroke, myocardial infarction, heart failure, and cardiovascular death 1
• The LIFE study demonstrated that better BP control reduces stroke risk by 25% 10
• Every 10 mmHg reduction in systolic BP reduces cardiovascular events 1
• Home BP monitoring should be implemented to demonstrate persistent elevation 1

Document the patient's refusal explicitly and the specific risks discussed, then offer close follow-up in 2 weeks (not 3-4 weeks) to reassess 1

---

Integrated Follow-Up Plan

2-Week Follow-Up (Not 3-4 Weeks)

Shorter interval required due to uncontrolled hypertension:

• Review home BP readings (should be checking daily) 1
• Reassess cardiovascular risk and medication adherence 1
• Strongly recommend Losartan dose increase if BP remains elevated 10

4-Week Follow-Up

• Review MRI cervical spine results (not X-ray) 1, 2
• Assess response to amitriptyline and celecoxib 7
• Evaluate need for physical therapy or specialist referral 7
• Recheck BP control 1

Surgical Referral Criteria

Refer to neurosurgery or spine surgery if:

• Persistent radicular pain after 6-8 weeks of optimized conservative therapy 4, 9
• Progressive motor weakness develops 5, 8
• MRI shows significant nerve root compression with clinical correlation 1, 4

---

Critical Pitfalls to Avoid

• Do not order cervical spine X-rays when MRI is indicated - X-rays cannot visualize disc pathology or nerve root compression 1, 2
• Do not delay imaging beyond 6-8 weeks of symptoms - this patient is already at 5 months 1, 2
• Do not accept patient refusal of BP medication intensification without extensive counseling - document risks explicitly 1
• Do not wait 3-4 weeks for BP reassessment - uncontrolled hypertension requires 2-week follow-up 1
• Do not interpret degenerative changes on imaging as causative without clinical correlation - 85% of asymptomatic individuals over 30 have spondylotic changes 2