What is the likely diagnosis and recommended management for intermittent electric‑shock pain radiating from the neck to the feet that worsens with walking?

Intermittent Electric-Shock Pain from Neck to Feet Worsening with Walking

This presentation is most consistent with cervical myelopathy causing spinal intermittent claudication, and you should obtain MRI of the cervical spine as the initial diagnostic test.

Clinical Diagnosis

The electric-shock sensation radiating from neck to feet that worsens with walking represents a classic presentation of spinal cord compression causing neurogenic symptoms. This differs fundamentally from peripheral neuropathy or lumbar pathology:

• Electric-shock pain radiating from the neck downward is a hallmark descriptor of cervical spinal cord involvement, not peripheral nerve disease 1, 2
• Worsening with walking indicates spinal intermittent claudication, where ambulation increases metabolic demands on an already compromised spinal cord 3
• The neck-to-feet distribution suggests cervical or upper thoracic cord compression rather than lumbar stenosis, which would not originate from the neck 3

Key Distinguishing Features

This is NOT peripheral neuropathy because:

• Peripheral neuropathic pain is invariably symmetrical and begins distally (feet first), then progresses proximally 2
• Neuropathic pain from small fiber dysfunction presents as burning, altered temperature perception, and "walking on marbles" sensations—not electric shocks from the neck 2
• Peripheral neuropathy does not originate from the neck and radiate downward 1, 2

This is NOT lumbar spinal stenosis because:

• Lumbar stenosis causes bilateral buttock and posterior leg pain, not symptoms originating from the neck 1
• Neurogenic claudication from lumbar stenosis improves with forward bending or sitting (postural relief pattern), which is not described here 1, 4
• Lumbar pathology cannot explain symptoms radiating from the cervical region 5, 6

Pathophysiology of Spinal Intermittent Claudication

The mechanism involves circulatory impairment of the spinal cord during ambulation:

• Walking increases metabolic demands on the compressed spinal cord, leading to relative ischemia 3
• Venous pooling occurs in the spinal cord between levels of compression, with failure of arterial vasodilation in response to exercise 5
• This creates a supply-demand mismatch that produces symptoms specifically with ambulation 3

Diagnostic Approach

Initial Imaging

Order MRI of the cervical spine immediately as the first-line test:

• MRI is the most sensitive test for detecting spinal cord compression and soft tissue abnormalities 1
• Look specifically for spinal canal stenosis, cord compression, and signal changes within the cord itself 1
• Radiographs are inadequate for evaluating spinal cord pathology 1

Clinical Examination Priorities

Document the following objective findings:

• Upper motor neuron signs: hyperreflexia, positive Babinski sign, clonus 3
• Gait abnormalities: spastic gait pattern, difficulty with tandem walking 3
• Sensory level: determine if there is a dermatomal level of sensory change 3
• Sphincter function: assess for bladder or bowel dysfunction indicating severe cord compression 3

Provocative Testing

• Gait loading test: have the patient walk until symptoms are reproduced, then document any objective neurological changes that appear with ambulation 3
• This test can reveal spinothalamic signs (pain and temperature sensation deficits) that emerge or worsen with walking 3

Critical Pitfalls to Avoid

Do not assume this is diabetic neuropathy or peripheral neuropathy:

• The neck origin and electric-shock quality radiating downward are incompatible with peripheral neuropathy 2
• Starting duloxetine or gabapentin for presumed neuropathic pain would delay diagnosis of a surgically correctable condition 2

Do not order lumbar spine imaging first:

• The symptom origin from the neck mandates cervical evaluation 1
• Lumbar stenosis does not cause symptoms originating from the cervical region 5, 6

Do not dismiss normal nerve conduction studies:

• Standard nerve conduction studies evaluate only large myelinated peripheral nerves and will be normal in spinal cord pathology 2

Management Based on MRI Findings

If Cervical Stenosis with Cord Compression is Confirmed

Urgent neurosurgical or spine surgery referral is indicated:

• Spinal intermittent claudication from cord compression requires decompression to prevent permanent neurological injury 3
• Surgical decompression provides immediate relief of symptoms in most cases 3
• Conservative management is not appropriate when progressive myelopathy is present 5

Red Flags Requiring Expedited Evaluation

• Progressive weakness in the legs 1
• Bladder or bowel dysfunction 1
• Difficulty with fine motor tasks in the hands (indicating cervical cord involvement) 3
• Falls or significant gait instability 3

Alternative Diagnoses to Consider

If MRI cervical spine is normal, consider:

• Thoracic spinal stenosis: can also cause spinal intermittent claudication with leg symptoms 3
• Multiple sclerosis: can present with Lhermitte's sign (electric-shock sensations with neck flexion) 1
• Vitamin B12 deficiency: can cause subacute combined degeneration of the spinal cord 2