Cervical Radiculopathy with Atypical Presentation

Pathophysiology and Clinical Presentation

Cervical radiculopathy occurs when a cervical nerve root is compressed or irritated, typically causing symptoms in a specific dermatomal distribution in the upper extremity 1
Most commonly affects C5-C6 and C7 nerve roots, with symptoms typically confined to the upper extremity 1

When unilateral arm and leg symptoms occur together, this raises concern for possible cervical myelopathy (spinal cord compression) rather than simple radiculopathy 2
Multiple levels of nerve root compression affecting both cervical and lumbar spine may also be a cause of atypical presentation 3
Plexopathy rather than radiculopathy is another possible cause of atypical presentation with leg symptoms 3, 4

MRI of the cervical spine is the preferred imaging modality to evaluate for cervical radiculopathy with atypical presentation 1, 5

Bilateral radiculopathy or symptoms affecting both upper and lower extremities may indicate risk for myelopathy, which requires more urgent evaluation 1
Cervical cord compression with long tract signs should be considered when symptoms affect both arm and leg unilaterally 2
Multiple sites of pathology should be considered when symptoms affect both arm and leg unilaterally 3, 4
Non-spinal causes such as multiple sclerosis or other neurological disorders should also be considered when symptoms affect both arm and leg unilaterally 3

Surgical decompression should be considered when there is persistent or progressive neurological deficit despite conservative management 6, 1
More comprehensive neurological workup is warranted for atypical presentation with both arm and leg symptoms 3, 4
MRI of both cervical and lumbar spine may be necessary for atypical presentation with both arm and leg symptoms 3
Neurology consultation should be considered for atypical presentation with both arm and leg symptoms 3, 4

The American College of Radiology suggests that the "electric" quality of pain described by the patient is characteristic of neuropathic pain seen in radiculopathy, which can help differentiate it from other conditions 7
The presentation of pain radiating in a specific dermatomal distribution with accompanying reflex changes is characteristic of radiculopathy rather than peripheral nerve entrapment, according to the American College of Radiology 7

The American College of Radiology notes that when evaluating cervical radiculopathy, assessing muscle stretch reflexes, such as the biceps reflex, provides localizing value for the affected nerve root, and in this case, the left-sided reflexes would not be expected to be abnormal in this unilateral presentation 7

The American College of Radiology recommends MRI of the cervical spine without contrast as the appropriate imaging modality for evaluating suspected cervical radiculopathy with atypical presentations, providing superior soft tissue visualization for detecting disc herniations and nerve root compression 8
MRI is preferred over other modalities for its ability to detect disc herniations and nerve root compression, with a success rate of 75-90% for conservative management of cervical radiculopathy 9

The American College of Radiology suggests that most cases of cervical radiculopathy, even with atypical presentations, respond to conservative management, which includes cervical collar immobilization, head traction, nonsteroidal anti-inflammatory drugs, and physical therapy with strengthening and stretching, with a success rate of 75-90% 8
Surgical intervention, such as anterior cervical surgery with complete decompression of the spinal cord and/or nerve root, is considered when conservative treatment fails after 4-6 weeks, with surgical outcomes for arm pain relief ranging from 80-90% 9

The American College of Radiology recommends magnetic resonance imaging (MRI) of the cervical spine without contrast as the first‑line imaging study for suspected cervical radiculopathy, because it correctly predicts approximately 88 % of lesions that cause nerve‑root impingement【10】.

The American College of Radiology emphasizes that MRI findings must be interpreted in the context of the patient’s clinical presentation, since asymptomatic individuals frequently have imaging abnormalities that do not correspond to symptoms【10】.