What are the possible causes and recommended workup for left cervical paresthesia with intermittent disequilibrium and no pain?

Evaluation of Left Cervical Paresthesia with Intermittent Disequilibrium

This presentation requires urgent vascular imaging with MRA head and neck to exclude vertebral artery dissection, which can present with unilateral neck paresthesia and imbalance without pain and may progress to posterior circulation stroke. 1

Immediate Red-Flag Assessment

The combination of unilateral cervical paresthesia with disequilibrium—particularly in the absence of pain—raises concern for vascular pathology that demands urgent evaluation:

• Vertebral artery dissection is a critical must-not-miss diagnosis that presents with neck paresthesia, imbalance, and often lacks significant pain; this can progress to cerebellar stroke 1
• Posterior circulation TIA may manifest as subtle imbalance with sensory symptoms and requires vascular imaging within 48 hours 1
• Cervical myelopathy from spinal cord compression presents with imbalance and paresthesias; screen for gait disturbance, hyperreflexia, and bowel/bladder dysfunction 2, 3

Recommended Diagnostic Algorithm

Step 1: Urgent Clinical Screening (Perform Immediately)

• Document the exact distribution of numbness/tingling to determine if dermatomal (nerve root) versus non-dermatomal (vascular or central) 2
• Assess for myelopathic signs: hyperreflexia, positive Hoffman sign, clonus, gait instability, bowel/bladder changes 2, 3
• Perform cerebellar testing: finger-to-nose, heel-to-shin, tandem gait to characterize the imbalance 1, 4
• Screen for constitutional symptoms (fever, weight loss, night sweats), history of trauma, malignancy, or immunosuppression 2, 3

Step 2: Urgent Vascular Imaging (Within 24-48 Hours)

Order MRA head and neck without contrast as the primary study because:

• MRA head and neck provides comprehensive evaluation of both intracranial and extracranial vasculature for vertebral artery dissection, which is the most time-sensitive diagnosis 1
• Most vertebral artery dissections are extracranial, making combined head and neck imaging superior to either alone 1
• This presentation lacks the typical severe pain of dissection, but painless dissection occurs and should not be missed 1, 2

Alternative if MRA unavailable or contraindicated: CTA head and neck with IV contrast provides equivalent vascular assessment 1

Step 3: Brain and Spinal Cord Imaging

Simultaneously order MRI cervical spine without contrast to evaluate for:

• Cervical myelopathy from spinal cord compression (disc herniation, stenosis, tumor) 2, 3
• Nerve root compression if symptoms follow a dermatomal pattern 3
• Intrinsic spinal cord pathology (demyelination, infarction, tumor) 2

Consider MRI brain without contrast if:

• Imbalance suggests cerebellar or brainstem pathology 1, 5
• Concern for posterior circulation infarction or demyelination 1, 6

Critical Differential Diagnoses by Presentation Pattern

Clinical Pattern	Most Likely Diagnosis	Urgent Action Required
Unilateral neck paresthesia + imbalance + no pain	Vertebral artery dissection	MRA head/neck within 24h [1]
Dermatomal paresthesia + imbalance + no neck pain	Cervical radiculopathy with incidental imbalance	MRI cervical spine, reassess gait [3]
Non-dermatomal paresthesia + progressive imbalance + hyperreflexia	Cervical myelopathy	MRI cervical spine emergently [2,3]
Paresthesia + episodic vertigo + imbalance	Posterior circulation TIA	MRA head/neck + MRI brain within 48h [1]

Common Pitfalls to Avoid

• Do not assume mechanical neck pathology simply because symptoms involve the neck; the absence of pain makes vascular and central causes more likely than musculoskeletal 2, 7
• Do not defer vascular imaging while pursuing conservative management; vertebral dissection can progress to stroke within hours to days 1
• Do not order plain radiographs or CT cervical spine alone; these modalities cannot evaluate the spinal cord, nerve roots, or vascular structures adequately 1, 3
• Do not interpret degenerative changes on imaging as causative without clinical correlation; 85% of asymptomatic individuals over 30 have cervical degenerative changes 2, 7

When Conservative Management Is Inappropriate

Unlike typical mechanical neck pain, this presentation should not be managed conservatively without imaging because:

• The absence of pain with neurological symptoms (paresthesia, imbalance) suggests non-mechanical pathology 2, 7
• Imbalance indicates possible posterior fossa, spinal cord, or vascular involvement requiring urgent evaluation 1, 5
• Delaying vascular imaging risks missing a dissection during the window for stroke prevention 1

Urgent Neurology Referral Criteria

Refer immediately if any of the following are present:

• Progressive motor weakness or sensory loss 3, 5
• Myelopathic signs on examination 2, 3
• Vascular abnormality identified on MRA/CTA 1
• Spinal cord compression or intrinsic cord signal abnormality on MRI 2, 3