What is the appropriate diagnosis and management for a patient experiencing tingling in the left scapula and weakness in the left hand?

Cervical Radiculopathy: Diagnostic Workup and Management

This presentation of tingling in the left scapula with left hand weakness is most consistent with cervical radiculopathy, likely at C6-C7 or C7-C8 levels, and requires immediate clinical neurological examination followed by MRI of the cervical spine without contrast to identify nerve root compression.

Initial Clinical Assessment

The combination of scapular paresthesias and hand weakness suggests a cervical nerve root lesion rather than a peripheral nerve injury. Key examination findings to document include:

• Motor testing: Assess wrist extension (C6-C7), finger extension (C7-C8), grip strength, and intrinsic hand muscle function 1
• Sensory distribution: Map the exact pattern of numbness and tingling to determine dermatomal involvement 1
• Reflex examination: Check biceps (C5-C6), triceps (C7), and brachioradialis reflexes for asymmetry 2
• Upper motor neuron signs: Test for hyperreflexia, Hoffman's sign, or Babinski response to exclude myelopathy 2

Diagnostic Imaging Algorithm

MRI cervical spine without IV contrast is the first-line imaging study for suspected cervical radiculopathy with motor weakness 1. This modality provides:

• Direct visualization of nerve root compression from disc herniation, foraminal stenosis, or osteophytes 1
• Assessment of spinal cord signal changes that would indicate myelopathy requiring urgent intervention 1
• Evaluation of soft tissue structures including ligaments and paraspinal muscles 1

Plain radiographs of the cervical spine are insufficient for this presentation, as they cannot visualize nerve roots or soft tissue compression 1.

Electrodiagnostic Studies

Nerve conduction studies (NCS) and needle electromyography (EMG) should be performed 3-4 weeks after symptom onset if the diagnosis remains unclear or to confirm the level of involvement 2, 3, 4. Earlier testing may yield false-negative results before Wallerian degeneration is complete 3.

Key electrodiagnostic findings in cervical radiculopathy include:

• Normal sensory nerve action potentials (SNAPs): Because the lesion is proximal to the dorsal root ganglion, sensory NCS remain normal despite sensory symptoms 5
• Denervation on needle EMG: Fibrillation potentials and positive sharp waves in a myotomal distribution confirm active denervation 2, 6
• Normal F-wave latencies: Unlike peripheral neuropathy, F-waves are typically preserved in radiculopathy 6

Both NCS and needle EMG must be performed together, as NCS alone will miss the diagnosis of radiculopathy in most cases 4. The needle examination should include cervical paraspinal muscles and at least 5 muscles in the affected limb to map the myotomal distribution 2.

Critical Differential Diagnoses to Exclude

Peripheral Nerve Injury

If there is a history of recent injection, trauma, or compression injury to the upper extremity, consider radial or median neuropathy 7, 3. However, peripheral nerve lesions typically produce:

• Abnormal SNAPs distal to the lesion (unlike radiculopathy) 5
• Non-dermatomal sensory loss 3
• Conduction block on proximal nerve stimulation 3

Motor Neuron Disease

Progressive weakness with fasciculations, muscle atrophy, and upper motor neuron signs suggests ALS 2. Electrodiagnostic findings include:

• Widespread denervation in non-myotomal distribution affecting multiple limbs 2
• Fasciculation potentials throughout the examination 2
• Normal sensory studies 2

Brachial Plexopathy

Scapular involvement combined with hand weakness could indicate lower trunk or medial cord plexus injury 3. Distinguishing features include:

• Abnormal SNAPs (unlike radiculopathy) 5
• Weakness crossing multiple nerve root distributions 3

Management Based on Severity

Conservative Management (First-Line)

For radiculopathy without progressive motor weakness or myelopathy:

• Physical therapy with gentle stretching and mobilization to improve range of motion and reduce nerve root compression 1
• Analgesics: Acetaminophen or NSAIDs for pain control 1
• Activity modification: Avoid positions that exacerbate radicular symptoms 8
• Gradual strengthening exercises once acute pain subsides, typically at 4-6 weeks 1

Interventional Options

If conservative management fails after 6-12 weeks:

• Epidural corticosteroid injections may provide temporary relief but do not alter long-term outcomes 1
• Duloxetine for neuropathic pain if numbness and tingling persist 1

Surgical Referral (Urgent Indications)

Immediate neurosurgical consultation is required for:

• Progressive motor weakness despite conservative treatment 1
• MRI evidence of spinal cord compression with myelopathic signs 1
• Cauda equina syndrome with bowel/bladder dysfunction 1

Common Pitfalls to Avoid

Do not order electrodiagnostic studies in the first 2-3 weeks after symptom onset, as needle EMG will not show denervation changes until Wallerian degeneration occurs, leading to false-negative results 3, 5.

Do not rely on NCS alone without needle EMG, as this will miss the diagnosis of radiculopathy in the majority of cases since sensory studies remain normal 4, 5.

Do not assume peripheral nerve injury without considering cervical pathology, especially when scapular symptoms are present, as this suggests a more proximal lesion 7, 3.

Do not delay MRI if there are any upper motor neuron signs, as cervical myelopathy requires urgent decompression to prevent permanent spinal cord injury 1, 2.