What is the next best step in managing a 36‑year‑old adult with neck pain radiating to the shoulders and arm, aggravated by cervical palpation and flexion/extension, who has failed physiotherapy, massage, and acupuncture and whose X‑ray shows mild C4‑C5 disc‑space narrowing?

Management of Cervical Radiculopathy with Failed Conservative Therapy

The next best step is to obtain an MRI of the cervical spine without contrast to evaluate for nerve root compression, disc herniation, or foraminal stenosis that may be amenable to surgical intervention. 1, 2

Rationale for MRI at This Stage

Your patient has completed an adequate trial of conservative therapy (physiotherapy, massage, acupuncture) without improvement and presents with radicular symptoms (pain radiating to shoulders and arm). 1

• MRI is the most sensitive imaging modality for detecting soft-tissue abnormalities, nerve root compression, and disc pathology, correctly predicting radiculopathy lesions in approximately 88% of cases. 2
• The American College of Radiology guidelines specify that MRI should be obtained after 6-12 weeks of failed conservative management in patients with persistent radicular symptoms. 2
• While X-ray has already shown mild C4-C5 disc space narrowing, plain radiographs cannot adequately assess nerve root compression, disc herniation, or foraminal stenosis—the key pathologies that determine whether surgical intervention is appropriate. 1

Why Not Continue Conservative Management?

• Although 75-90% of cervical radiculopathy cases resolve with conservative treatment, your patient has already failed multiple modalities over an adequate timeframe. 2
• The presence of pain with neck palpation and flexion/extension, combined with radiating arm pain, suggests mechanical nerve root compression that warrants anatomic evaluation. 1
• Continuing the same conservative approach without imaging risks prolonging disability in a patient who may benefit from targeted interventions (epidural steroid injections or surgery). 3, 4

What the MRI Will Clarify

The MRI will determine:

• Presence and level of disc herniation compressing nerve roots. 1, 3
• Degree of foraminal stenosis from uncovertebral or facet joint hypertrophy. 1
• Spinal cord compression (myelopathy), which would change management urgency. 2
• Correlation between imaging findings and clinical symptoms to guide surgical planning if needed. 2, 3

Red Flags to Assess Before MRI

Before ordering the MRI, ensure the patient does not have any of these urgent red flags that would require immediate imaging and referral:

• Progressive motor weakness not explained by pain alone. 2
• Bilateral upper extremity symptoms or combined upper/lower extremity involvement (suggesting myelopathy). 2
• New bladder or bowel dysfunction. 2
• Loss of perineal sensation. 2
• Gait disturbance or difficulty with fine motor tasks (dropping objects, buttoning). 2

If any of these are present, obtain MRI urgently and refer to spine surgery immediately. 2

Next Steps After MRI

If MRI Shows Significant Pathology:

• Refer to spine surgery if there is clear nerve root compression correlating with symptoms, especially if pain remains intractable after 6-12 weeks. 2, 3
• Consider selective nerve root blocks for diagnostic confirmation and temporary relief while planning definitive management. 4, 5
• Surgical intervention (anterior cervical discectomy and fusion, posterior foraminotomy, or disc arthroplasty) achieves 80-90% relief of arm pain in appropriately selected patients. 2, 5

If MRI is Negative or Shows Only Mild Changes:

• Reconsider the diagnosis—shoulder pathology, peripheral nerve entrapment (thoracic outlet syndrome, carpal tunnel syndrome), or myofascial pain may mimic cervical radiculopathy. 6, 5
• CT myelography can be considered if MRI is equivocal or contraindicated, as it may better visualize foraminal stenosis and bony lesions. 1

Common Pitfalls to Avoid

• Do not assume X-ray findings alone justify surgery. Degenerative changes (disc space narrowing, osteophytes) are common in asymptomatic adults over 30 years and correlate poorly with symptoms. 1, 2
• Do not mistake referred cervical pain for primary shoulder pathology. Pain radiating to the shoulder that worsens with neck movement or palpation is cervical in origin until proven otherwise. 2, 6
• Do not order MRI with contrast unless there is suspicion for infection, tumor, or prior posterior cervical surgery with concern for epidural scarring. 1
• Be aware that MRI has a 25-40% false-positive rate for soft-tissue abnormalities in asymptomatic individuals, so correlation with clinical findings is essential. 1, 7

Alternative Consideration: CT of Cervical Spine

• CT provides excellent bony detail and can assess foraminal stenosis from uncovertebral or facet hypertrophy, particularly at C6-C7 where visualization on X-ray is limited. 1
• However, CT is less sensitive than MRI for nerve root compression and soft-tissue pathology, making it a second-line option. 1
• CT may be appropriate if MRI is contraindicated (pacemaker, severe claustrophobia) or if bony pathology is the primary concern. 1