A 36-year-old previously healthy man comes to the office due to neck pain. Two days ago, the patient was lifting weights when he suddenly experienced neck and upper back pain. He has had constant dull pain and intermittent sharp pain with neck movements that radiates to his left hand. He also reports a tingling sensation in the left hand but has had no weakness or bladder or bowel dysfunction. Vital signs are within normal limits. Physical examination shows cervical paraspinal muscle spasm. There is mildly decreased sensation to pinprick in the left fourth and fifth digits. There are no other sensory deficits and no upper or lower extremity muscle weakness is present. Deep tendon reflexes are normal throughout. Which of the following is the most appropriate next step in management of this patient?

Question

A 36-year-old previously healthy man comes to the office due to neck pain.  Two days ago, the patient was lifting weights when he suddenly experienced neck and upper back pain.  He has had constant dull pain and intermittent sharp pain with neck movements that radiates to his left hand.  He also reports a tingling sensation in the left hand but has had no weakness or bladder or bowel dysfunction.  Vital signs are within normal limits.  Physical examination shows cervical paraspinal muscle spasm.  There is mildly decreased sensation to pinprick in the left fourth and fifth digits.  There are no other sensory deficits and no upper or lower extremity muscle weakness is present.  Deep tendon reflexes are normal throughout.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d588_508a_bc81_8ff5d866165b_MD0003_00 This patient has had an acute onset of neck and back pain that radiates to the left hand with neck movements. In association with sensory deficits in the 4^th and 5^th digits, this presentation is suggestive of a C8 cervical radiculopathy. Manifestations of cervical radiculopathies vary depending on the involved nerve root, but typically include neck or arm pain and sensory and/or motor deficits that extend in a dermatomal and myotomal pattern. Neck movement may worsen the impingement, leading to radiation of the pain down the arm. Radiculopathies most often occur due to compression of the nerve root due to disk herniation (evidenced by acute symptom onset, as seen in this patient) or progressive spinal spondylosis (evidenced by subacute or progressive symptom onset). The diagnosis is typically made clinically, and neuroimaging is not required in patients with mild deficits and low risk of malignancy or infection (eg, absence of fever, weight loss, or progressive neurologic deficits). compression of the nerve root Most patients experience gradual resolution; therefore, treatment should focus on symptom management with nonsteroidal anti-inflammatory drugs (NSAIDs) and avoidance of provocative maneuvers. However, patients should maintain moderate physical activity as able; strict bedrest should be avoided. Oral glucocorticoids can be added for patients with severe pain. (Choices A and C) Because most cases of cervical radiculopathy are self-limiting, neuroimaging is usually not required. MRI is recommended only for patients with severe, progressive, or bilateral neurologic deficits, or in those with high concern for malignancy or epidural abscess (eg, fever, intravenous drug use). X-ray is used to evaluate for a possible compression fracture or suspected vertebral metastases but has limited use in cervical radiculopathy. (Choice B) Epidural corticosteroid injections are often the next step in management for patients who fail to improve with NSAIDs and behavioral modifications or oral glucocorticoids. (Choice E) Surgical intervention is indicated for patients with progressive neurologic deficits (especially motor deficits), evidence of spinal cord compression (myelopathy), or severe, persistent symptoms. However, neuroimaging would be required prior to surgery. Educational objective: Cervical radiculopathy is due to nerve root compression and typically presents with neck or arm pain associated with sensorimotor deficits; radiation of pain with neck movement may occur. The diagnosis is usually made clinically, and most patients improve with symptomatic treatment, including nonsteroidal anti-inflammatory drugs and avoidance of triggering activities.

A 36-Year-Old Previously Healthy Man Comes to the Office Due