A 60-year-old man comes to the office due to right-sided neck and shoulder pain. The pain worsens with neck movement and is associated with numbness in his forearm. Over the past 2 years, he has had several episodes of similar symptoms that improved with rest and ibuprofen. The patient has no history of neck or shoulder trauma. He smokes a pack of cigarettes daily and has used injection drugs in the past. Vital signs are within normal limits. Physical examination shows limited neck rotation and lateral bending. There is decreased pinprick sensation on the posterior aspect of the right forearm but no muscle weakness. Triceps reflex is normal. Left upper and bilateral lower extremity examination show no other abnormalities. A plain radiograph of the cervical spine is ordered. This patient's symptoms are most likely associated with which of the following radiographic findings?

Question

A 60-year-old man comes to the office due to right-sided neck and shoulder pain.  The pain worsens with neck movement and is associated with numbness in his forearm.  Over the past 2 years, he has had several episodes of similar symptoms that improved with rest and ibuprofen.  The patient has no history of neck or shoulder trauma.  He smokes a pack of cigarettes daily and has used injection drugs in the past.  Vital signs are within normal limits.  Physical examination shows limited neck rotation and lateral bending.  There is decreased pinprick sensation on the posterior aspect of the right forearm but no muscle weakness.  Triceps reflex is normal.  Left upper and bilateral lower extremity examination show no other abnormalities.  A plain radiograph of the cervical spine is ordered.  This patient's symptoms are most likely associated with which of the following radiographic findings?

Quizplus · Accepted Answer

11ec25c8_d555_0b4b_bc81_a5817d6a4bdc_MD0003_00 This patient's episodic neck/shoulder pain, reduced neck mobility, and sensory changes in his forearm raise suspicion for cervical radiculopathy. Most cases arise in older adults due to acute cervical disc herniation or underlying cervical spondylosis. Cervical spondylosis is a degenerative condition of the spine marked by osteophyte formation in the facet and uncovertebral joints, which leads to neural foramina narrowing. Although many cases are asymptomatic, some patients develop nerve root compression (radiculopathy) with neck/shoulder pain and upper extremity sensory, motor, and/or reflex abnormalities in a dermatomal distribution. In patients with spondylosis, sclerotic facet joints with osteophytes can be seen on cervical spine films, but MRI is often obtained in those who have motor or reflex abnormalities as it better visualizes the spine and surrounding soft tissues. (Choice A) Atlantoaxial subluxation can occur in patients with rheumatoid arthritis, leading to compressive cervical myelopathy. Manifestations generally begin with neck pain that radiates to the occiput, but patients frequently develop progressive spastic paresis, Lhermitte sign (shock like sensation down the spine), and lower extremity manifestations. Episodic neck/shoulder pain and forearm paresthesia would be atypical. (Choice B) Thoracic and lumbar compression fractures usually occur in the setting of underlying osteoporosis; they typically manifest with focal spinal pain/tenderness, not radiculopathy. Cervical compression fractures are uncommon and usually occur in the setting of high-impact trauma. (Choice D) Spinal metastasis or osteomyelitis can cause focal osteolytic lesions; these conditions generally cause local spine pain/tenderness. Neither is likely to cause episodes of neck/shoulder pain over 2 years. (Choice E) Odontoid process fracture usually occurs in the setting of high-impact trauma (eg, motor vehicle collision) and generally results in spinal cord compression (myelopathy), not radiculopathy. (Choice F) Vertebral body squaring is an early sign of ankylosing spondylitis, an inflammatory condition of the spine that generally presents with chronic, progressive neck/back pain in a patient age <40. Radiculopathy would be atypical; most patients have pain that is worse at night and improves with activity. Educational objective: Cervical radiculopathy often arises in older individuals due to underlying cervical spondylosis. Manifestations generally include neck pain that radiates to the shoulder/arm and unilateral upper extremity sensory, motor, and/or reflex abnormalities in a dermatomal distribution. Spine imaging generally shows abnormal facet joints, including the presence of sclerosis and osteophytes.

A 60-Year-Old Man Comes to the Office Due to Right-Sided