Last reviewed: March 2026
Contents
MDM Templates
Cervical Radiculopathy
Patient presents with neck pain radiating to the upper extremity in a dermatomal distribution consistent with cervical radiculopathy. They deny bowel or bladder dysfunction, gait instability, and bilateral upper extremity symptoms. Neurological exam demonstrates intact strength and sensation without upper motor neuron signs.
History and exam lower suspicion for cervical myelopathy, central cord syndrome, cervical fracture, epidural abscess, arterial dissection, and anginal equivalent. C-spine imaging deferred — patient is negative by NEXUS criteria.
Plan: NSAIDs. Outpatient physical therapy. Home exercise program in the interim.
Disposition: Discharge with return precautions for new weakness, gait difficulty, or bowel/bladder changes. Follow up with PCP within 1 week.
Cervical Strain
Patient presents with neck pain without radicular symptoms. They deny numbness, weakness, gait instability, and bowel or bladder dysfunction. Well appearing with full range of motion, no midline tenderness, no focal neurological deficits.
History and exam lower suspicion for cervical fracture, disc herniation with cord compression, epidural abscess, arterial dissection, and anginal equivalent. Imaging deferred per NEXUS criteria.
Plan: NSAIDs and muscle relaxant. Activity as tolerated.
Disposition: Discharge with return precautions for new weakness, numbness, or worsening symptoms. Follow up with PCP as needed.
Central Cord Syndrome
Patient presents after injury with bilateral upper extremity weakness greater than lower extremity weakness, consistent with central cord syndrome. This is a spinal cord emergency.
Emergent MRI obtained. Neurosurgery consulted regarding imaging findings, neurological deficits, and need for surgical decompression.
Plan: C-spine immobilization maintained. Analgesia. Foley catheter if urinary retention present.
Disposition: Admit for neurosurgical management.
Clinical Education
NEXUS and Canadian C-Spine Rules
The NEXUS criteria and Canadian C-Spine Rule both safely identify patients who don’t need imaging. NEXUS is simpler (5 criteria — no midline tenderness, no focal deficit, normal alertness, no intoxication, no distracting injury). The Canadian rule is more sensitive (~99.4% vs ~99.0%) and more specific, but slightly more complex. Either is acceptable — use whichever your shop prefers.[1]
Neither rule applies to patients under 16. For pediatric cervical spine clearance, clinical judgment and a lower threshold for imaging are appropriate.
Cervical Radiculopathy Pearls
Know the root levels. C5 (deltoid weakness, lateral arm numbness), C6 (biceps/wrist extension weakness, thumb/index numbness — diminished brachioradialis reflex), C7 (triceps/wrist flexion weakness, middle finger numbness — diminished triceps reflex), C8 (grip/intrinsic hand weakness, ring/small finger numbness). The disc herniates at the level above the affected root — C6 radiculopathy = C5-C6 disc herniation.[2]
Spurling test is the most useful exam maneuver. Extend and laterally flex the neck toward the symptomatic side, then apply axial compression. Reproduction of radicular symptoms is a positive test — specificity ~93%, but sensitivity is only ~50%. A negative Spurling test doesn’t rule out radiculopathy.
MRI is rarely indicated from the ED. Like lumbar radiculopathy, most cervical disc herniations improve with conservative management over 6–12 weeks. MRI is an outpatient study unless you have red flags (myelopathy signs, progressive weakness, bowel/bladder dysfunction).
Cervical Myelopathy Red Flags
Myelopathy means the spinal cord itself is compressed — this changes everything. Red flags that distinguish myelopathy from simple radiculopathy: gait instability or ataxia, bilateral upper extremity symptoms, upper motor neuron signs (hyperreflexia, clonus, Babinski, Hoffman sign), bowel or bladder dysfunction, and “hand clumsiness” (difficulty with buttons, writing). Any of these findings warrant emergent MRI and neurosurgical consultation.[3]
Hoffman sign is the upper extremity equivalent of Babinski — flick the middle finger DIP and watch for involuntary thumb/index finger flexion. Quick to test and a useful screening tool for cervical myelopathy.
Cervical Artery Dissection
Neck pain with new neurological symptoms should always raise the question of arterial dissection. Vertebral artery dissection can present as posterior neck pain with posterior circulation symptoms (vertigo, dysarthria, diplopia, ataxia). Carotid dissection presents as anterior neck pain or headache, often with ipsilateral Horner syndrome and contralateral weakness. Risk factors include recent neck trauma (even minor — chiropractic manipulation, sports), connective tissue disorders, and age <50.[4]
CTA neck is the study of choice in the ED. If dissection is confirmed, anticoagulation (heparin then warfarin) or antiplatelet therapy is initiated — consult neurology for the specific regimen.
ED Treatment
NSAIDs are first-line for both cervical strain and radiculopathy. Add a muscle relaxant (cyclobenzaprine 10 mg TID) for significant spasm. A short course of oral corticosteroids (prednisone 60 mg x 5 days) is reasonable for acute cervical radiculopathy with significant pain — similar evidence base as for lumbar radiculopathy.[5]
Avoid cervical collars for non-traumatic neck pain. They promote deconditioning and don’t improve outcomes. Encourage gentle range of motion and activity as tolerated. Physical therapy referral is the most evidence-based intervention for persistent symptoms.
References
- Stiell IG et al. The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med. 2003;349(26):2510-2518. PubMed
- Iyer S, Kim HJ. Cervical radiculopathy. Curr Rev Musculoskelet Med. 2016;9(3):272-280. PubMed
- Nouri A et al. Degenerative cervical myelopathy: epidemiology, genetics, and pathogenesis. Spine. 2015;40(12):E675-E693. PubMed
- Debette S, Leys D. Cervical-artery dissections: predisposing factors, diagnosis, and outcome. Lancet Neurol. 2009;8(7):668-678. PubMed
- Cohen SP. Epidemiology, diagnosis, and treatment of neck pain. Mayo Clin Proc. 2015;90(2):284-299. PubMed
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