What does the cervical spine radiograph show and what is the appropriate management for a patient with acute neck pain and left‑sided upper‑back tingling, given mild levoconvex curvature and mild right‑sided foraminal narrowing at C3‑4?

Cervical Spine Radiograph Interpretation and Management

What the Radiograph Shows

This cervical spine X-ray demonstrates essentially normal findings with only minor degenerative changes that do not explain the patient's left-sided symptoms. 1

The key findings are:

• Preserved vertebral body and disc heights – No significant degenerative disc disease or compression fractures 1
• Normal lateral alignment – No subluxation, listhesis, or loss of lordosis 1
• Mild levoconvex curvature on AP view – A slight leftward curve that is a common normal variant and not associated with neck pain 2
• Mild right-sided foraminal narrowing at C3-4 – This is on the opposite side from the patient's left-sided symptoms, making it clinically irrelevant 1
• No left-sided foraminal narrowing – The symptomatic side shows no bony abnormality 1

Critical Clinical Mismatch

The radiographic findings do not correlate with the clinical presentation of acute left-sided neck pain and upper back tingling. The mild right C3-4 foraminal narrowing is anatomically discordant with left-sided symptoms and should be considered an incidental finding. 1, 2

Appropriate Next Steps

Immediate Management

MRI of the cervical spine without IV contrast is the appropriate next imaging study for this patient with acute neck pain and radiculopathy when plain radiographs are non-diagnostic. 1

The ACR Appropriateness Criteria (2025) rates MRI cervical spine without contrast as "usually appropriate" (rating 9/9) for acute cervical pain with radiculopathy, as it provides:

• Superior visualization of soft tissue abnormalities including disc herniations 1
• Assessment of nerve root compression and spinal cord signal abnormalities 1
• Detection of acute disc pathology not visible on radiographs 1
• Evaluation of the left-sided neural foramina and nerve roots corresponding to symptoms 1

Conservative Treatment During Workup

While awaiting MRI, initiate multimodal conservative therapy:

• NSAIDs (ibuprofen 400-800 mg three to four times daily) for pain control 3
• Avoid opioids – they provide no additional benefit and carry significant risks 3
• Cervical manipulation or mobilization 1-2 times per week if no red flags present 3
• Range-of-motion exercises emphasizing gentle movements 3

Red Flags Requiring Urgent Evaluation

Screen for concerning features that would necessitate urgent MRI with and without IV contrast 4:

• Progressive neurological deficits (weakness, gait disturbance, bowel/bladder dysfunction) 4
• Fever, night sweats, or unexplained weight loss (suggesting infection) 4
• History of malignancy 1, 4
• Elevated inflammatory markers (CRP, ESR) 4
• Trauma history 1
• Intractable pain despite appropriate therapy 3

Common Pitfalls to Avoid

Do not assume the right-sided C3-4 foraminal narrowing explains left-sided symptoms – this represents anatomic-clinical discordance and pursuing treatment directed at the wrong level would be inappropriate. 1

Do not dismiss symptoms based on normal radiographs – plain films have limited sensitivity for soft tissue pathology, disc herniations, and early nerve root compression that are readily apparent on MRI. 1

Do not order interventional procedures (facet injections, epidural steroid injections) without MRI confirmation of pathology, as the ACR strongly recommends against these for mechanical neck pain. 3

Recognize that mild curvature abnormalities are not pathologic – studies demonstrate no significant association between cervical spine curvature variations and neck pain in adults. 2, 5

Expected Timeline

• MRI should be obtained within 1-2 weeks for acute radiculopathy without red flags 1
• Most acute neck pain resolves within 6 weeks with conservative management, though 50% may have residual or recurrent episodes up to 1 year 3
• Reassess at 4 weeks – if symptoms persist beyond 3 months despite appropriate conservative management, surgical consultation may be warranted based on MRI findings 3