What causes neck pain with arm numbness and tingling, and what is the recommended management?

Neck Pain with Arm Numbness and Tingling

Cervical radiculopathy from nerve root compression by herniated disc or osteophyte is the most common cause of neck pain with arm numbness and tingling, and most cases (75-90%) resolve with conservative management within 6-8 weeks without requiring imaging unless red flags are present. 1, 2

Immediate Assessment: Screen for Red Flags

Before proceeding with any imaging or treatment, systematically evaluate for urgent conditions requiring immediate MRI: 1, 2

• Constitutional symptoms: fever, unexplained weight loss, night sweats 1, 2
• History of malignancy or immunosuppression 1, 2
• Progressive neurological deficits: weakness, gait disturbance, bilateral symptoms 1, 2
• Myelopathic signs: difficulty with fine motor tasks, hyperreflexia, positive Hoffmann sign, bladder/bowel dysfunction 1, 3
• Elevated inflammatory markers: ESR, CRP, WBC count 1, 2
• History of IV drug use (infection risk) 1, 2
• Intractable pain despite appropriate conservative therapy 1, 2
• Vertebral body tenderness on palpation 2

Diagnostic Algorithm

If Red Flags Present:

Order MRI cervical spine without contrast immediately to exclude serious pathology including vertebral osteomyelitis, discitis, metastatic disease, inflammatory arthritis, primary spinal tumors, or cervical myelopathy. 1, 2 MRI is superior to all other imaging modalities with 88% accuracy in predicting nerve root lesions compared to 81% for CT myelography. 2

If No Red Flags Present:

Do not order imaging initially. 1, 2 Proceed directly to conservative management, as imaging leads to overdiagnosis of incidental degenerative changes that correlate poorly with symptoms—85% of asymptomatic individuals over 30 years show spondylotic changes on imaging. 2

Clinical Examination Findings

Document the specific dermatomal distribution to localize the affected nerve root: 2

• Spurling's test (axial compression with neck extension and rotation toward symptomatic side) is highly specific for nerve root compression from herniated disc 2, 3
• Sensory deficits in dermatomal pattern 4
• Motor weakness in myotomal distribution 4
• Reflex changes (diminished biceps, triceps, or brachioradialis reflexes) 3

Conservative Management (First-Line Treatment)

Initiate multimodal conservative therapy immediately for patients without red flags: 2, 3

• NSAIDs for pain control 5
• Physical therapy with strengthening and stretching exercises 3
• Cervical collar immobilization (short-term use only) 3
• Head traction may provide symptom relief 3
• Short-term corticosteroid therapy for severe inflammation 5

Expected outcome: 75-90% of cervical radiculopathy cases resolve with conservative nonoperative therapy. 2, 6 However, approximately 50% of patients will have residual or recurrent pain up to 1 year after initial presentation. 6

When to Order MRI (After Conservative Trial)

Consider MRI cervical spine without contrast if: 1, 2

• Persistent symptoms beyond 6-8 weeks of appropriate conservative therapy 1, 2
• Progressive neurological deficits develop during treatment 2
• Severe pain unresponsive to conservative measures 2

Escalation to Interventional/Surgical Management

If symptoms persist despite 4-6 weeks of conservative therapy and MRI confirms nerve root compression: 3

• Cervical epidural steroid injections for persistent radicular pain 2
• Surgical decompression (anterior cervical discectomy) for:
  • Severe or progressive neurological deficits 3
  • Debilitating pain refractory to conservative and interventional treatment 4
  • Cord compression or myelopathy 5, 4
  • Surgical outcomes show 80-90% relief of arm pain 3

Critical Pitfalls to Avoid

Do not order immediate imaging in acute presentations without red flags. This leads to unnecessary costs and overdiagnosis of asymptomatic degenerative changes present in 53.9% of the general population aged 18-97. 2, 6 Degenerative changes on MRI correlate poorly with clinical symptoms—a 10-year longitudinal study showed 85% of patients had progression of cervical disc degeneration but only 34% developed symptoms. 2

Do not misdiagnose vertebral artery dissection as simple radiculopathy. Though rare, vertebral artery dissection can present with neck pain and arm paresthesia following minor trauma, but will progress to rotational vertigo and cerebellar signs. 7 This requires immediate vascular imaging if suspected.

Do not miss cervical myelopathy. Bilateral symptoms, lower extremity involvement, gait disturbance, or hyperreflexia indicate spinal cord compression rather than simple radiculopathy and require urgent surgical evaluation. 1, 3