What is the best initial management approach for a 30-year-old female patient with chronic cervical pain, tenderness at the C7 (cervical spine) area, and exacerbation of pain with knee flexion, with a normal X-ray (radiograph) result?

Cervical Radiculopathy with Atypical Presentation: Immediate MRI Cervical Spine Required

This patient requires MRI of the cervical spine without contrast as the next diagnostic step, as the pain exacerbation with knee flexion suggests possible cervical radiculopathy with atypical presentation or tension sign indicating nerve root involvement. 1, 2

Critical Clinical Recognition

The key finding here is pain at C7 that worsens with knee flexion—this represents a positive slump test or tension sign, indicating neural tissue involvement and possible cervical radiculopathy with atypical lower extremity manifestations. 1

• When cervical pain is accompanied by symptoms that extend beyond typical dermatomal patterns (such as pain provocation with lower extremity movements), this raises concern for either cervical myelopathy, multiple-level nerve root compression, or plexopathy rather than simple mechanical neck pain. 1
• The American College of Radiology emphasizes that bilateral symptoms or symptoms affecting both upper and lower extremities may indicate cervical cord compression with long tract signs, requiring urgent evaluation. 1

Why MRI is Mandatory Now

MRI cervical spine without contrast is the appropriate imaging modality for suspected cervical radiculopathy with atypical presentations, providing superior soft tissue visualization for detecting disc herniations and nerve root compression. 1, 2

• The normal X-ray does not exclude significant pathology—radiographs are often not needed in cervical pain evaluation and do not influence management or improve clinical outcomes. 3
• MRI is the most sensitive imaging modality for assessing soft tissue abnormalities, including disc herniations, nerve root compression, and spinal cord pathology. 3, 2
• Approximately 65% of asymptomatic patients aged 50-59 have radiographic evidence of significant cervical spine degeneration, making plain films poorly correlate with symptoms. 4

Red Flags Present in This Case

This patient demonstrates concerning features requiring urgent evaluation:

• Atypical pain pattern with lower extremity provocation suggests possible cervical myelopathy or multiple-level pathology. 1
• Progressive or persistent neurological symptoms warrant immediate advanced imaging. 1, 2
• The American College of Radiology states that symptoms affecting both upper and lower extremities may indicate cervical myelopathy rather than simple radiculopathy. 1, 2

Management Algorithm

Immediate Actions:

• Order MRI cervical spine without contrast to evaluate for disc herniation, nerve root compression, or spinal cord pathology. 1, 2
• Perform detailed neurological examination focusing on upper motor neuron signs (hyperreflexia, Hoffman's sign, Babinski sign, clonus) to assess for myelopathy. 1
• Assess for additional red flags: progressive motor weakness, bilateral symptoms, bladder/bowel dysfunction, or loss of perineal sensation. 1, 2

If MRI Confirms Radiculopathy Without Myelopathy:

• Conservative management achieves symptomatic relief in 75-90% of cervical radiculopathy cases. 2, 5, 6
• Initiate multimodal conservative treatment: NSAIDs for pain control, physical therapy with cervical strengthening and stretching exercises, and consider cervical collar for short-term immobilization. 1, 5, 7
• Epidural corticosteroid injection (interlaminar approach) may be considered for acute/subacute radicular pain if conservative measures fail after 4-6 weeks. 1, 7

If MRI Shows Myelopathy or Progressive Deficits:

• Urgent neurosurgical consultation is required for consideration of surgical decompression. 1
• Surgical intervention (anterior cervical decompression) provides 80-90% relief of arm pain when conservative treatment fails. 1

Critical Pitfalls to Avoid

• Do not dismiss atypical presentations—pain provocation with knee flexion in a patient with cervical tenderness is not typical mechanical neck pain and requires investigation for neural involvement. 1
• Do not rely on normal X-rays to exclude significant pathology—radiographs lack sensitivity for disc herniations, nerve root compression, and spinal cord pathology. 3, 4
• Do not delay MRI when atypical features are present—symptoms affecting both cervical region and lower extremities warrant immediate advanced imaging to rule out myelopathy. 1, 2
• Do not overinterpret degenerative findings on MRI—high rates of abnormalities exist in asymptomatic patients, so correlation with clinical findings is essential. 3, 4