What is the recommended treatment for a 26-year-old patient with bilateral numbness and stiffness in the fourth and fifth fingers, exacerbated by sleeping position, and MRI findings of loss of cervical lordosis at C6-C7?

Treatment Recommendation for 26-Year-Old with Bilateral 4th/5th Finger Symptoms and Loss of Cervical Lordosis at C6-C7

This patient requires conservative management with physical therapy focused on cervical extensor strengthening, not surgery, as the clinical presentation does not match the imaging findings and suggests peripheral nerve compression (likely ulnar nerve) rather than cervical myelopathy.

Critical Clinical-Radiological Mismatch

The presenting symptoms are inconsistent with the MRI findings and warrant careful diagnostic reconsideration:

• Bilateral 4th and 5th finger numbness and stiffness exacerbated by sleeping position is classic for ulnar nerve compression at the elbow (cubital tunnel syndrome), not cervical pathology 1
• Loss of cervical lordosis at C6-C7 would be expected to cause bilateral hand weakness affecting multiple muscle groups (biceps, triceps, wrist extensors, finger flexors), burning dysesthesias in forearms, and potentially lower extremity involvement—none of which are described in this patient 2, 1
• The positional nature of symptoms (worse with sleeping position) strongly suggests peripheral nerve entrapment rather than central pathology 3

Why Surgery is Contraindicated

Recent evidence from 2025 demonstrates significant risks of early surgical intervention in patients without true myelopathy:

• A 37-year-old patient with actual spinal cord signal change and documented weakness who underwent urgent decompression within 48 hours experienced worsening of symptoms postoperatively, with progression from grade 4/5 to 0/5 finger strength 3
• The same study emphasizes that early surgical intervention for spinal cord injury without fracture-dislocation "may not be necessary, or may even be harmful" 3
• Patients with isolated loss of cervical lordosis without true myelopathic signs do not require surgical decompression 3

Recommended Conservative Management

Initial Diagnostic Clarification

• Perform comprehensive neurological examination including all upper extremity myotomes systematically, reflexes, gait assessment, and sensory testing in dermatomal distribution 2
• Consider nerve conduction studies to evaluate for ulnar neuropathy at the elbow, given the classic distribution and positional nature 1
• MRI findings of loss of lordosis correlate poorly with neck pain in patients >30 years of age and are commonly seen in asymptomatic individuals 3

Physical Therapy Protocol

• Cervical extensor muscle strengthening is specifically indicated for patients with loss of cervical lordosis, as these patients demonstrate significant weakness in neck extensors with a reduced extension/flexion strength ratio 4
• Exercise programs should focus on restoring balance between flexor and extensor muscles 5
• The cross-sectional area of the semispinalis capitis is significantly reduced in patients with loss of cervical lordosis, making targeted extensor strengthening essential 5

Additional Conservative Measures

• Spinal manipulation combined with intermittent motorized cervical traction has demonstrated complete symptom relief and restoration of cervical lordosis at 4-year follow-up in patients with cervical radiculopathy and reversed lordosis 6
• Modification of sleeping position to avoid prolonged elbow flexion if ulnar nerve compression is confirmed 1

Red Flags Requiring Urgent Imaging or Intervention

None of these are present in this patient, but monitor for:

• Progressive motor weakness affecting multiple myotomes bilaterally 1
• Bilateral symptoms affecting both upper AND lower extremities 1
• New bladder or bowel dysfunction 1
• Gait disturbance 2
• Loss of perineal sensation 1

Prognosis with Conservative Management

• Most cases of acute cervical neck pain with radicular symptoms resolve spontaneously or with conservative treatment measures 3
• Patients with favorable preoperative cervical extension capacity (eROM ≥9.3°) demonstrate spontaneous restoration of initial lordosis and would be good candidates for laminoplasty if surgery were ever needed, but this is not indicated now 7
• Early recognition and treatment before onset of actual spinal cord damage is essential for optimal outcomes 8

Common Pitfalls to Avoid

• Do not operate based on imaging findings alone without corresponding myelopathic clinical signs 3, 2
• Do not assume bilateral hand symptoms automatically indicate cervical myelopathy—consider peripheral nerve pathology 2, 1
• Avoid attributing symptoms to incidental MRI findings of loss of lordosis, which are common and often asymptomatic 3