What should be done for a patient with left-sided neck pain who has developed shoulder numbness?

Evaluation and Management of Left-Sided Neck Pain with Shoulder Numbness

For a patient presenting with left-sided neck pain and new shoulder numbness, you must immediately assess for cervical radiculopathy with focused neurological examination and consider urgent imaging if red flag symptoms are present, while simultaneously evaluating for referred pain from shoulder pathology.

Initial Clinical Assessment Priority

Critical Red Flag Screening

You need to immediately rule out serious pathology before proceeding with conservative management:

• Assess for myelopathy signs: Test for Hoffmann sign bilaterally, evaluate gait, check for lower extremity weakness or sensory changes, and assess bladder/bowel function 1, 2
• Screen for vascular injury: In patients over 50 years, consider vertebral artery dissection, especially if there was recent neck trauma, manipulation, or prolonged neck extension—this can present with neck pain and neurological symptoms 3
• Evaluate for progressive neurological deficits: Document the exact distribution of numbness (dermatomal pattern suggests radiculopathy; non-dermatomal suggests peripheral nerve or referred pain) 1, 4
• Check for systemic symptoms: Fever, weight loss, history of malignancy, or intravenous drug use warrant immediate advanced imaging 1

Distinguish Cervical Radiculopathy from Referred Shoulder Pain

The key diagnostic challenge is that shoulder impingement can present as neck pain with referred symptoms, while cervical radiculopathy presents with neck pain radiating to the shoulder 5:

• Cervical radiculopathy pattern: Pain radiates from neck down the arm in a dermatomal distribution, with motor weakness in specific myotomes and diminished reflexes 1, 4
• Referred shoulder pain pattern: Pain localizes to the superomedial scapular region near the neck, worsens with shoulder elevation above 90 degrees, and improves with arm at rest 5
• Perform impingement testing: If the patient has a positive Neer or Hawkins sign with pain referred to the neck region, this suggests shoulder impingement as the primary pathology 6, 5

Diagnostic Imaging Algorithm

When Imaging is NOT Initially Required

In the absence of red flags, imaging may be deferred for 4-6 weeks while pursuing conservative treatment 1:

• No progressive neurological deficits
• No myelopathy signs
• Symptoms present less than 6 weeks
• Patient can participate in conservative therapy

When to Obtain Immediate MRI Cervical Spine

Order MRI without contrast urgently if any of the following are present 1, 4:

• Progressive motor weakness or sensory loss
• Positive Hoffmann sign or other upper motor neuron signs
• Symptoms refractory to 6 weeks of conservative treatment
• History of malignancy, infection risk, or trauma
• Age over 50 with sudden onset after neck manipulation or extension 3

Role of Plain Radiographs

Plain cervical spine radiographs have limited utility in this presentation but may be considered to assess for gross instability or degenerative changes if MRI is not immediately available 1, 4

Initial Management Strategy

If Cervical Radiculopathy is Suspected

Most acute cervical radiculopathy resolves spontaneously or with conservative treatment within 6-12 weeks 4:

• Pharmacological management: Start scheduled NSAIDs (if no contraindications) combined with acetaminophen for pain control 7, 4
• Consider muscle relaxants: There is evidence supporting short-term use (5-7 days) for acute neck pain with muscle spasm 4
• Neuropathic pain features: If numbness is accompanied by burning, shooting pain, or allodynia, trial amitriptyline 25-75 mg at bedtime or gabapentin titrated to effect 7
• Avoid prolonged immobilization: Cervical collars should be limited to 3-5 days maximum to prevent deconditioning 4

If Shoulder Impingement with Referred Pain is Suspected

Perform diagnostic subacromial injection with lidocaine and corticosteroid 5:

• If neck pain resolves immediately after subacromial injection, this confirms shoulder impingement as the primary source
• Instruct patient to avoid shoulder elevation above 90 degrees
• Initiate rotator cuff and scapular stabilizer strengthening program 6, 5

Physical Therapy Prescription

Exercise therapy is beneficial for neck pain and should be initiated early 1, 4:

• Focus on gentle range-of-motion exercises initially
• Progress to strengthening of cervical paraspinal and scapular stabilizer muscles
• Avoid overhead pulley exercises which can worsen both cervical and shoulder pathology 6, 7
• Include postural correction and ergonomic modifications

Critical Pitfalls to Avoid

• Do not assume all neck pain with arm symptoms is radiculopathy: Shoulder impingement commonly presents as neck pain in the superomedial scapular region 5
• Do not delay MRI if red flags are present: Myelopathy, infection, malignancy, and vascular injury require urgent diagnosis 1, 3
• Do not prescribe epidural steroid injections without clear radicular symptoms: Evidence for epidural injections in cervical radiculopathy is conflicting, and recent guidelines strongly recommend against their routine use 1, 4
• Do not ignore atypical presentations: Parsonage-Turner syndrome (neuralgic amyotrophy) can present with neck pain followed by progressive shoulder weakness and numbness, particularly in the post-viral setting 8

Follow-Up and Reassessment

Re-evaluate at 2 weeks 4:

• If symptoms are improving with conservative care, continue current management
• If symptoms are unchanged or worsening, obtain MRI cervical spine
• If new neurological deficits develop, obtain urgent MRI and neurosurgical consultation 1, 4

At 6 weeks, if symptoms persist despite conservative treatment, MRI is indicated to guide further management, which may include interventional procedures or surgical consultation 1, 4