What is the appropriate evaluation and management for left-sided cervical paresthesia persisting for three months?

Evaluation and Management of Left-Sided Cervical Paresthesia Persisting Three Months

Immediate Red-Flag Assessment

Screen urgently for progressive neurological deficits, myelopathic signs, or alternative diagnoses before attributing symptoms to mechanical neck pain. 1

Your priority is to identify features that mandate imaging and specialist referral:

• Progressive motor weakness (hand clumsiness, gait instability, difficulty with fine motor tasks) suggests degenerative cervical myelopathy requiring urgent neurosurgical evaluation 2
• Hyperreflexia, bilateral Hoffman reflexes, or sensorimotor deficits indicate spinal cord compression, not simple radiculopathy 2
• Bilateral symptoms, saddle anesthesia, or bowel/bladder dysfunction require immediate MRI 1
• History of malignancy, unexplained weight loss, fever, or vertebral body tenderness necessitates urgent imaging to exclude infection or tumor 3

Clinical Examination Priorities

Perform a focused neurological examination targeting:

• Forehead function to exclude central (stroke) versus peripheral facial nerve pathology if facial symptoms are present 4
• Upper extremity motor testing by specific myotomes (C5 deltoid, C6 biceps/wrist extensors, C7 triceps, C8 finger flexors) to localize nerve root involvement 5
• Sensory examination in dermatomal distribution to correlate with imaging findings 5
• Deep tendon reflexes (biceps C5-6, triceps C7, brachioradialis C6) and pathological reflexes (Hoffman sign) to detect myelopathy 2
• Cervical range of motion and provocation testing, though these rarely alter management in the absence of red flags 1

Imaging Decision Algorithm

Do NOT order imaging for mechanical neck pain without red flags—radiographic findings rarely correlate with symptoms and do not change conservative management. 1

Order MRI cervical spine without contrast if:

• Symptoms persist beyond 3 months despite appropriate conservative therapy 1
• Any red-flag features are present (progressive deficits, myelopathic signs, trauma history) 3, 1
• Clinical examination reveals objective neurological deficits (weakness, reflex changes, dermatomal sensory loss) that correlate with radicular symptoms 5

Avoid routine plain radiographs—they have poor sensitivity (36%) for cervical injuries and do not influence initial conservative treatment 3, 1

First-Line Conservative Management Protocol

Initiate a structured 4-week multimodal program combining manual therapy, supervised exercise, and NSAIDs. 1

Manual Therapy Component

• Cervical manipulation or mobilization 1-2 times per week for 4 weeks 1
• Target restrictions throughout the cervical spine as identified on examination 6
• Spinal manipulative therapy may benefit uncomplicated mechanical neck pain and cervical proprioceptive impairment 7, 6

Exercise Protocol

• Cervical and scapulothoracic stabilization exercises 3 times per week for minimum 4 weeks 1
• Include range-of-motion exercises emphasizing all planes of movement 1
• Progress to strengthening exercises targeting cervical extensors and deep neck flexors 1
• Address cervical proprioceptive impairment through joint position sense retraining 7

Pharmacological Management

• Ibuprofen 400-800 mg three to four times daily for pain control 1
• Avoid opioids—they provide no additional benefit and carry significant risks 1

Interventions to Avoid

Do NOT perform interventional procedures (facet joint injections, epidural steroid injections, radiofrequency ablation) for mechanical neck pain—these lack evidence and may cause harm 1

Do NOT use cervical traction, TENS, or laser therapy—insufficient evidence supports these modalities 3, 1

Reassessment Timeline and Escalation

• Reassess at 4 weeks for pain, disability, and range of motion 1
• Most acute neck pain resolves within 6 weeks, but 50% may have residual or recurrent episodes up to 1 year 1
• If symptoms persist beyond 3 months despite appropriate conservative management, order MRI to evaluate for structural pathology requiring surgical consideration 1, 5

Special Diagnostic Considerations

Neck-Tongue Syndrome

If the patient reports tongue numbness specifically triggered by neck rotation, consider neck-tongue syndrome caused by C1-2 dysfunction 6. This presents as unilateral upper neck pain with ipsilateral tongue numbness during brisk rotation and responds favorably to cervical manipulation 6.

Cervical Radiculopathy

If dermatomal arm pain, sensory loss, or motor weakness is present, 75-90% of patients achieve symptomatic relief with nonoperative conservative therapy 5, 8. MRI is the preferred imaging modality to confirm nerve root compression 5, but imaging should only be ordered if it will change management (i.e., surgical candidacy after failed conservative care) 1.

Degenerative Cervical Myelopathy

Myelopathy may present with varied symptoms including neck pain, hand numbness, and torso dysesthesia 2. The presence of hyperreflexia, bilateral Hoffman reflexes, or progressive motor deficits mandates urgent neurosurgical referral 2. Delayed diagnosis is common because symptoms overlap with radiculopathy 2.

Common Pitfalls

• Ordering premature MRI in the absence of red flags generates false-positive findings (asymptomatic disc abnormalities are common) and does not improve outcomes 1
• Attributing all neck and arm symptoms to radiculopathy without screening for myelopathy can delay life-altering surgical intervention 2
• Prescribing opioids for mechanical neck pain provides no benefit over NSAIDs and introduces addiction risk 1
• Performing interventional procedures (injections, ablations) for mechanical neck pain wastes resources and exposes patients to procedural risks without evidence of benefit 1