What is the diagnosis?

The shoulder x-ray is normal. On physical examination the patient has full range of motion, normal strength, and negative special testing of the shoulder. However, Spurling’s maneuver is positive. On further questioning the patient states he can have shooting pains down the arm and endorses occasional paresthesias in the distal right upper extremity. 

The diagnosis is cervical radiculopathy. 

• Pearl: Pain in the shoulder can at times be coming from the neck. Be sure to consider this if there are not any localizing findings on shoulder examination. 

What is the mechanism of injury?

Symptoms typically are caused by nerve compression, chemical irritation, or neuropraxia. These symptoms are usually indolent without a specific preceding injury or trauma. 

What physical exam findings are expected?

Physical exam findings can vary widely depending on which nerve/root is involved. Oftentimes patients will complain of symptoms in the upper extremity, but examination of those portions of the extremity will not elicit any findings. Spurling’s maneuver may be positive in these patients. You can find a video of how to perform it here.

It is possible for patients to have sensory changes or weakness on exam, which can be in a dermatomal/myotomal pattern. 

Image 2. Dermatome Map, courtesy of Wikipedia Commons

• Pearl: A common pneumonic to remember cervical myotome strength testing is Blocker (C5, deltoid), Beggar (C6, Bicep and Wrist Extension), Kisser (C7, Triceps and Wrist Flexion), Grabber (C8, Grip strength), Spock (T1, Finger Abduction)

• Pearl: Persistent neurologic deficits would indicate an urgent referral. 

Which imaging modalities can be used?

This is primarily a clinical diagnosis based on physical exam findings. X-ray imaging of the area of complaint will often be negative.

Plain films of the cervical spine can be a good first step to ensure there are no obvious injuries and may show degenerative changes. If these are negative, MRI imaging is the gold standard if symptoms are not improving or if there are constant neurological deficits [1].  

EMG testing as an outpatient can be used to identify what level the nerve is being affected at. 

What is the management in the ED?

If there are no persistent neurologic changes, patients can be treated symptomatically with NSAIDs or oral steroids [1]. Topical interventions such as lidocaine patches and diclofenac gel can be beneficial as well. Home exercise programs and/or physical therapy referral can also be considered.

In the long term, non operative management has been found to be successful 83% of the time if secondary to disc herniation [2]. 

• Pearl: Palpate the neck musculature. If symptoms are secondary to muscle spasms, you can also consider trigger point injections as seen here. 

When do you consult Orthopedics?

Orthopedics should be consulted any time there is a persistent neurologic deficit. Otherwise, if symptoms have not been improving for >6-8 weeks consider an outpatient orthopedic spine referral. 

• Pearl: A pain management referral can be considered as well for potential corticosteroid injection.