What is the most likely diagnosis and first‑line treatment for a patient with a bulging, tender paraspinal muscle in the upper back accompanied by neck and shoulder pain and finger numbness, without red‑flag features?

Clinical Diagnosis: Cervical Radiculopathy with Cervical Strain

This presentation is most consistent with cervical radiculopathy accompanied by cervical strain, and the first-line treatment is conservative multimodal therapy including NSAIDs, physical therapy with strengthening and stretching exercises, and reassurance that 75-90% of cases resolve without surgery. 1, 2

Diagnostic Reasoning

The combination of neck/shoulder pain, finger numbness (radicular symptoms), and tender paraspinal muscles points to nerve root compression with concomitant cervical musculature injury. 1, 3, 4

Key Clinical Features Supporting This Diagnosis:

• Finger numbness indicates dermatomal sensory changes from nerve root compression, typically from herniated disc or osteophyte impingement with an annual incidence of 83 per 100,000 persons 1, 3, 4

• Tender paraspinal muscles with bulging appearance represents cervical strain, characterized by pain/tenderness on palpation of paraspinal and suboccipital muscles, which commonly occurs alongside cervical radiculopathy due to shared injury mechanisms 1

• Neck and shoulder pain radiating patterns are classic for C5-C7 nerve root involvement, the most common levels affected in cervical radiculopathy 3, 4, 2

Critical Red Flag Assessment Required:

Before proceeding with conservative treatment, you must systematically screen for red flags that would mandate immediate MRI: 1, 3

• Constitutional symptoms (fever, unexplained weight loss, night sweats) 1, 3
• History of malignancy or IV drug use 1, 3
• Progressive motor weakness or myelopathic signs (gait disturbance, bowel/bladder dysfunction) 1, 3
• Intractable pain despite appropriate therapy 1, 3
• Vertebral body tenderness on midline palpation (not paraspinal tenderness) 1, 3
• Elevated inflammatory markers (ESR, CRP, WBC) 3, 5

First-Line Treatment Protocol (Absence of Red Flags)

If no red flags are present, imaging is NOT indicated initially, as most acute cervical radiculopathy resolves spontaneously with conservative management within 6-8 weeks. 1, 3, 2

Specific Conservative Treatment Components:

• NSAIDs for pain control and anti-inflammatory effect 2, 6

• Physical therapy focusing on:

  • Cervical strengthening exercises for paraspinal musculature 2, 6
  • Stretching to improve range of motion 2, 6
  • Potentially cervical traction for temporary nerve decompression 6

• Muscle relaxants for paraspinal muscle spasm 2

• Short-term cervical collar use (avoid prolonged immobilization) 6

• Massage therapy for muscular component 2

• Patient reassurance that 75-90% of cervical radiculopathy cases resolve with nonoperative therapy 1, 4, 2

When to Escalate Care

Order MRI cervical spine without contrast if: 1, 3, 2

• Symptoms persist beyond 6-8 weeks of appropriate conservative therapy 1, 3, 2
• Progressive neurological deficits develop 1, 3
• Severe pain unresponsive to multimodal treatment 1, 3
• Any red flag symptoms emerge 1, 3

MRI is 88% accurate in predicting nerve root lesions compared to 81% for CT myelography, making it the preferred imaging modality when indicated. 1, 3

Critical Pitfalls to Avoid

• Do not order immediate imaging in the absence of red flags – this leads to overdiagnosis of incidental degenerative changes present in 53.9% of asymptomatic individuals, with prevalence increasing with age 1, 3

• Do not interpret degenerative changes on imaging as causative without clinical correlation – 65% of asymptomatic patients aged 50-59 show significant cervical degeneration on radiographs 1, 3

• Do not confuse paraspinal muscle tenderness (cervical strain) with vertebral body tenderness (red flag for infection/malignancy) 1, 3

• Do not miss thoracic outlet syndrome – would present with vascular/neurogenic symptoms during arm elevation or specific positions, not typical paraspinal tenderness 3

• Recognize that approximately 50% of patients may have residual or recurrent symptoms within one year, but this does not change the initial conservative approach 3, 4

Subsequent Management After MRI (If Obtained)

If MRI confirms nerve root compression correlating with clinical symptoms: 3

• Continue multimodal conservative therapy 3, 2
• Consider cervical epidural steroid injections if symptoms persist (though higher risk of serious complications) 2
• Refer for surgical evaluation only if severe or progressive neurological deficits 3

If MRI shows no significant compression or findings don't correlate with symptoms: 3

• Reassess clinical diagnosis 3
• Consider EMG/nerve conduction studies to differentiate cervical radiculopathy from peripheral nerve entrapment (carpal tunnel syndrome, thoracic outlet syndrome) 3, 7