What is the diagnosis and treatment for a patient experiencing episodes of pain radiating from the middle back to the neck and down the shoulders, followed by painful contractures of the arms and hands, lasting several minutes?

Diagnosis: Cervical Radiculopathy vs. Cervical Myelopathy

This presentation of pain radiating from the middle back to neck and shoulders, followed by painful contractures of the arms and hands lasting several minutes, most likely represents cervical radiculopathy with possible myotomal involvement, though cervical myelopathy must be urgently excluded given the bilateral upper extremity involvement and episodic nature. 1

Critical Red Flags Requiring Immediate Evaluation

Immediate MRI of the cervical spine is indicated because bilateral upper extremity symptoms with motor involvement (contractures) raise concern for cervical myelopathy from spinal cord compression. 1, 2

Key features demanding urgent assessment include:

• Bilateral arm and hand involvement suggests spinal cord pathology rather than isolated nerve root compression 2
• Episodic painful contractures lasting several minutes may represent myotomal spasm from nerve root irritation or early myelopathic changes 1
• Gait disturbance, hyperreflexia, bowel/bladder dysfunction, or lower extremity symptoms would confirm myelopathy and require emergency neurosurgical consultation 2

Diagnostic Approach

Physical Examination Priorities

Perform a focused neurologic examination assessing for myelopathic signs versus radicular patterns:

• Test for hyperreflexia, Hoffman sign, Babinski sign, and clonus to identify upper motor neuron involvement indicating myelopathy 2
• Assess dermatomal sensory distribution and myotomal motor strength in both upper extremities to localize nerve root levels 1, 3
• Evaluate for Spurling test (neck extension with lateral rotation toward symptomatic side) which provokes radicular symptoms 3
• Document any gait abnormalities, particularly wide-based or spastic gait patterns 2

Imaging Strategy

MRI cervical spine without contrast is the imaging modality of choice because it provides superior visualization of the spinal cord, nerve roots, intervertebral discs, and foraminal stenosis without radiation exposure. 1, 2

• MRI should be obtained immediately rather than waiting 4-6 weeks given the bilateral nature and episodic contractures 2
• CT myelography is an alternative only if MRI is contraindicated 1
• Plain radiographs are insufficient for evaluating soft tissue pathology and should not delay MRI 2

Differential Diagnosis Considerations

Cervical Radiculopathy (Most Likely)

Pain radiating in a dermatomal distribution from disc herniation or foraminal stenosis typically affects one side, though bilateral involvement can occur with central disc herniation or multilevel disease. 1, 2

Cervical Myelopathy (Must Exclude)

Bilateral upper extremity symptoms with motor involvement are concerning for spinal cord compression, which requires urgent surgical evaluation to prevent permanent neurologic disability. 2

Brachial Plexopathy (Less Likely)

Plexopathy manifests as pain with neuropathic character in more than one peripheral nerve distribution, but the episodic nature and bilateral involvement make this less likely. 1

Thoracic Outlet Syndrome (Consider)

Neurogenic pectoralis minor syndrome can mimic cervical radiculopathy with neck pain radiating to shoulders and upper extremities, but typically presents with chronic rather than episodic symptoms. 4

Treatment Algorithm

If Myelopathy is Confirmed

Immediate neurosurgical referral is mandatory because surgical decompression is the only treatment that prevents progressive neurologic deterioration. 2

If Isolated Radiculopathy Without Myelopathy

First-line management consists of NSAIDs for pain control combined with activity modification (remaining active rather than bed rest). 2, 5

• NSAIDs provide moderate pain relief with good evidence for acute radicular pain 6
• Skeletal muscle relaxants can be added for short-term relief of associated muscle spasm 6
• Superficial heat application has good evidence for moderate benefit 6

Physical therapy and exercise should be initiated after the acute phase (typically 2-4 weeks) focusing on cervical stabilization and posture correction. 2, 4

Spinal manipulation may provide benefit for acute symptoms but should be used cautiously given the bilateral nature of symptoms. 2

Interventions to Avoid

Do NOT offer epidural steroid injections, as the most recent BMJ guideline provides a strong recommendation against epidural injection of local anesthetic, steroids, or their combination for chronic radicular spine pain. 6

Do NOT obtain routine imaging in the absence of red flags, as this does not improve outcomes and identifies many abnormalities that correlate poorly with symptoms—however, this patient HAS red flags (bilateral involvement with contractures). 2

Surgical Referral Timing

Immediate surgical referral is indicated for:

• Progressive motor deficits or bilateral upper extremity weakness 2
• Confirmed cervical myelopathy on MRI 2
• Severe radicular pain unresponsive to conservative measures within 2 weeks 6, 2

Elective surgical referral after 4-6 weeks of conservative therapy is appropriate for persistent radicular symptoms without myelopathy in surgical candidates. 2

Common Pitfalls

Failing to recognize cervical myelopathy leads to permanent neurologic disability from delayed surgical decompression—bilateral upper extremity symptoms should trigger immediate MRI rather than a trial of conservative therapy. 2

Misdiagnosing cervical radiculopathy as shoulder pathology (rotator cuff disease) or peripheral nerve entrapment delays appropriate treatment—the radiation pattern from middle back to neck then shoulders and arms suggests cervical spine origin. 7

Overlooking neurogenic pectoralis minor syndrome in patients with persistent symptoms despite negative cervical imaging can result in prolonged disability—consider diagnostic ultrasound-guided pectoralis minor muscle block if standard workup is unrevealing. 4