What is the diagnosis and treatment for a 26-year-old patient with stiffness and numbness in the little and fourth fingers of both hands, exacerbated by sleeping on either side, with MRI findings showing loss of cervical lordosis at C6-C7, also known as military neck?

Diagnosis and Management of Positional Hand Numbness with Loss of Cervical Lordosis

Primary Diagnosis

This 26-year-old patient most likely has cervical radiculopathy affecting the C8 nerve root distribution (4th and 5th fingers), caused by positional nerve compression related to loss of cervical lordosis at C6-C7, with symptoms exacerbated by sleeping positions that further compromise the neural foramina. 1

Clinical Reasoning

The symptom pattern is highly characteristic:

• Bilateral 4th and 5th finger numbness and stiffness indicates C8 nerve root involvement, as these fingers are innervated by the C8 dermatome 2
• Position-dependent symptoms (worse when sleeping on the affected side) suggest dynamic foraminal narrowing rather than fixed compression, which is typical in younger patients with loss of cervical lordosis 1, 3
• Loss of cervical lordosis (military neck) at C6-C7 creates biomechanical stress that can lead to foraminal stenosis and nerve root irritation, particularly in certain head positions 1, 4

Initial Management Approach

Conservative Treatment (First-Line - 6-8 Weeks)

Start with a structured conservative management program, as most cervical radiculopathy cases resolve without surgery, and early surgical intervention may be harmful in patients without fracture or acute cord compression. 1, 2

Specific interventions to implement:

• Supervised cervical extensor strengthening exercises are critical, as loss of cervical lordosis correlates with cervical extensor muscle weakness and flexor-extensor imbalance 4
• NSAIDs (ibuprofen 400-600mg three times daily) for pain control 5
• Avoid prolonged neck flexion positions during sleep - use a cervical pillow that maintains neutral alignment 5, 3
• Physical therapy focusing on restoring cervical lordosis through postural correction and traction may provide long-term benefit 3, 2
• Consider short-term cervical collar use (maximum 1-2 weeks) only for severe symptoms, as prolonged use causes muscle deconditioning 2

Red Flags Requiring Urgent Evaluation

Immediately obtain MRI cervical spine if any of the following develop: 1, 6

• Progressive motor weakness (not just numbness)
• Bilateral symptoms with gait disturbance or hyperreflexia (suggests myelopathy, not radiculopathy)
• Constitutional symptoms (fever, weight loss)
• Intractable pain despite conservative management
• History of malignancy or immunosuppression

Imaging Strategy

For this patient without red flags, imaging is NOT required at initial presentation. 1, 5

However, given the patient already has MRI showing loss of cervical lordosis:

• Review the MRI specifically for: 1, 6

  • Disc herniation at C6-C7 or C7-T1 (C8 nerve root exits below C7)
  • Foraminal stenosis from uncovertebral joint hypertrophy
  • Spinal cord signal changes (would indicate myelopathy, not radiculopathy)
  • Congenital canal narrowing

• Loss of cervical lordosis alone does NOT explain symptoms - up to 42% of asymptomatic individuals have straight cervical spines 7

• The key is identifying actual nerve root compression, not just alignment abnormalities 6, 8

Critical Pitfall to Avoid

Do not assume the loss of cervical lordosis is the primary pathology requiring surgical correction. 1, 8

• Recent evidence suggests that in patients with spinal cord injury without fracture or dislocation (SCIwoFD), early surgical intervention may worsen outcomes 1
• One case series showed a patient who underwent urgent decompression for similar presentation developed complete loss of hand function postoperatively (0/5 finger flexors and abductors) 1
• Another patient with similar imaging findings who was managed conservatively experienced complete recovery within months 1

When to Consider Advanced Intervention

Reassess at 6-8 weeks. Consider MRI and specialist referral if: 5, 6

• Symptoms persist or worsen despite 6-8 weeks of conservative management
• Progressive motor deficits develop
• Significant functional impairment affecting work or quality of life

If MRI confirms nerve root compression with persistent symptoms after conservative management:

• Selective nerve root blocks may provide diagnostic and therapeutic benefit 2
• Surgical decompression should only be considered after exhausting conservative options and with clear correlation between imaging findings and clinical symptoms 1, 2

Prognosis

The overall prognosis is favorable - most patients with cervical radiculopathy improve with conservative management. 2

• Younger age (26 years) is a positive prognostic factor 1
• Position-dependent symptoms (rather than constant) suggest dynamic compression with better potential for conservative management 3
• Restoration of cervical lordosis through conservative measures has been documented to provide long-term symptom relief 3