01Approach to the Critical Patient/attcp35

Triage and immediate threats

›Time critical triggers

›Progressive objective weakness

›If rapid progression, emergent MRI cervical spine

›If airway compromise from neck pathology, escalate to resuscitation bay

›Cervical myelopathy features

›If gait disturbance or hand clumsiness, emergent MRI cervical spine

›If bowel or bladder dysfunction, emergent spine consultation

›Spinal epidural abscess risk

›If fever plus neck pain plus neurologic deficit, initiate sepsis pathway and emergent MRI

›If IVDU or recent spinal procedure, lower threshold for MRI

›Malignancy concern

›If known cancer plus night pain or weight loss, urgent MRI

›If new severe unremitting pain at rest, urgent imaging

›Stabilization priorities

›Neurologic status trend

›If worsening motor deficit, spine consultation now

›If new long tract signs, treat as cord compression until proven otherwise

›Pain control without oversedation

›If severe pain limiting exam, initiate multimodal analgesia

›If opioid used, reassessment for neurologic change after analgesia

Key concepts

›Working diagnosis frame

›Cervical nerve root compression or inflammation

›Common mechanisms

›Foraminal stenosis from spondylosis

›Disc herniation with nerve root irritation

›Symptom pattern

02History/hx47

Symptom characterization

›Pain and neurologic pattern

›Distribution

›Dermatomal arm pain

›Scapular and interscapular radiation

›Quality and intensity

›Sharp shooting pain

›Burning or electric sensation

›Temporal features

›Onset time

›Progression over days to weeks

›Provoking and relieving factors

›Neck extension or rotation worsening

›Shoulder abduction relief sign

›Associated neurologic symptoms

›Sensory symptoms

›Numbness and tingling

›Sensory loss distribution

›Motor symptoms

›Grip weakness

›Wrist or elbow weakness pattern

›Myelopathy screen

›Gait imbalance

›Hand dexterity change

›Urinary retention or incontinence

Risk context and red flags

›Infection and inflammatory risks

›Systemic features

03Physical Exam/exam44

Neurologic exam focused

›Motor and sensory mapping

›Myotomes

›C5 deltoid and biceps

›C6 wrist extension

›C7 triceps and wrist flexion

›C8 finger flexion

›T1 finger abduction

›Dermatomes

›C5 lateral upper arm

›C6 thumb and radial forearm

›C7 middle finger

›C8 ring and small fingers with ulnar forearm

›T1 medial forearm

›Reflexes

›Biceps C5 C6

›Brachioradialis C6

›Triceps C7

›Myelopathy assessment

›Upper motor neuron signs

›Hyperreflexia

›Hoffmann sign

›Gait and balance

›Tandem gait difficulty

›Spastic gait pattern

›Long tract findings

›Clonus

›Babinski sign

04Differential Diagnosis/ddx38

Life threatening and high consequence

›Cord level pathology

›Cervical myelopathy

›ICD-10 M47.12

›SNOMED CT cervical myelopathy concept

›Spinal epidural abscess

›ICD-10 G06.1

›Fever and neurologic deficit as key clues

›Epidural hematoma

›Anticoagulation or bleeding disorder context

›Acute severe pain with rapid neurologic decline

›Vascular and cardiopulmonary

›Cervical artery dissection

›ICD-10 I77.71 or I77.74 depending on vessel

›Headache or focal neurologic symptoms

›Acute coronary syndrome with referred arm pain

›ICD-10 I21 and I20 spectrum

›Exertional or autonomic symptoms

Common mimics and overlapping disorders

›Peripheral nerve entrapment

›Carpal tunnel syndrome

›ICD-10 G56.0

›Median nerve distribution and nocturnal symptoms

›Ulnar neuropathy at elbow

›ICD-10 G56.2

›Medial hand symptoms and elbow provocation

›Musculoskeletal shoulder pathology

›Rotator cuff disease

05Laboratory Tests/lt24

Indicated labs only for red flags

›Infection evaluation set

›Complete blood count for fever or systemic symptoms

›Leukocytosis supports but does not confirm infection

›Normal count does not exclude epidural abscess

›C reactive protein for suspected spinal infection

›Elevation supports inflammatory or infectious process

›Normal value lowers likelihood but does not exclude

›Blood cultures if febrile or concern for bacteremia

›Two sets before antibiotics when feasible

›Positive cultures support hematogenous seeding

›Inflammatory and malignant evaluation set

›Erythrocyte sedimentation rate for spinal infection or malignancy concern

›High sensitivity adjunct for epidural abscess risk stratification

›Normal value does not exclude early disease

›Calcium and alkaline phosphatase if malignancy concern

›Hypercalcemia support for metastatic disease

›Elevated alkaline phosphatase suggests bony involvement

›Alternative diagnosis labs when indicated

›Troponin if ischemic symptoms or atypical arm pain pattern

›Follow local chest pain pathway timing

›ECG interpretation alongside troponin trend

›Pregnancy test if imaging anticipated and pregnancy possible

›MRI without gadolinium generally preferred if urgent imaging needed

›CT use risk benefit discussion when time critical

06Diagnostic Tests/dt81

Scoring Systems

›Trauma imaging decision rules

›Canadian C spine rule for alert stable trauma patients

›High risk factors

›Age 65 years or older

›Dangerous mechanism

›Paresthesias in extremities

›Low risk factors allowing safe range of motion assessment

›Simple rear end motor vehicle collision

›Sitting position in ED

›Ambulatory at any time

›Delayed onset neck pain

›No midline cervical tenderness

›Active rotation 45 degrees left and right requirement

›If unable, cervical spine imaging

›If able, imaging not required by rule

›NEXUS criteria

›Imaging not required only if all present

›No midline cervical tenderness

›No intoxication

›Normal alertness

›No focal neurologic deficit

›No painful distracting injury

›Functional severity tools for follow up

›Neck Disability Index use in outpatient tracking

›Baseline functional limitation measure

›Improvement tracking over weeks

MRI

›MRI cervical spine indications

›Neurologic deficit progression

›Objective weakness or worsening sensory loss

›New bowel or bladder dysfunction

›Myelopathy concern

›Hyperreflexia or gait disturbance

›Bilateral symptoms with long tract signs

›Infection or malignancy concern

›Fever or elevated inflammatory markers with pain

›Known cancer with new focal neurologic signs

›MRI protocol and interpretation pearls

›Non contrast sequences for initial evaluation

›T2 cord signal change suggests myelopathy

›Foraminal stenosis correlates with radicular symptoms but may be incidental

›Contrast use for infection or tumor concern

›Epidural enhancement supports abscess or phlegmon

›Vertebral marrow signal change supports osteomyelitis

›Limitations

›High prevalence of asymptomatic degenerative findings

›Imaging findings must match dermatomal and myotomal pattern

›Avoid over attribution when symptoms discordant

›Access and timing constraints

›If unstable neurologic status, transfer to MRI capable facility if needed

›Sedation risks in severe pain or claustrophobia

CT

›CT cervical spine indications

›Trauma evaluation per decision rules

›Suspected fracture or dislocation

›High risk mechanism with midline tenderness

›Suspected bony lesion when MRI not available

›Severe pain with malignancy concern

›Suspected destructive bony process

›CT technique and pearls

›Multidetector CT with thin slices

›High sensitivity for fracture

›Lower utility for soft tissue nerve root compression compared with MRI

›CT myelography role

›Consider if MRI contraindicated and surgical planning needed

›Requires specialist involvement

›CT limitations and safety

›Degenerative changes common

›Osteophytes and foraminal narrowing frequent incidental findings

›Clinical correlation required

›Radiation exposure

›Avoid routine CT for uncomplicated nontraumatic radiculopathy

Ultrasound

›Ultrasound limited direct role

›Alternate diagnosis support

›Shoulder ultrasound for effusion or bursitis when shoulder primary

›Soft tissue ultrasound for abscess in neck or upper back region if suspected

›Vascular adjunct when indicated

›Upper extremity venous ultrasound for suspected DVT with swelling

›Carotid ultrasound not adequate to exclude dissection

›Ultrasound guided procedures outside ED routine

›Selective nerve root injection typically outpatient

›Specialist referral pathway

›Not first line in acute ED care

07Disposition/dispo18

Level of care and follow up

›Admission and urgent specialist involvement

›Spine or neurosurgery consultation triggers

›Progressive weakness

›Myelopathy signs

›Suspected epidural abscess or hematoma

›Inpatient monitoring considerations

›Uncontrolled pain requiring parenteral therapy

›Unsafe discharge due to neurologic deficit or functional impairment

›Discharge with outpatient pathway

›Uncomplicated cervical radiculopathy criteria

›No red flags

›Stable neurologic exam without progressive deficit

›Follow up targets

›Primary care or sports medicine within 1 to 2 weeks

›Physiotherapy referral if symptoms persist

›Imaging follow up triggers

›Persistent symptoms beyond 4 to 6 weeks despite conservative therapy

›New objective weakness at any time

08Treatment/t78

Analgesia and activity strategy

›Nonpharmacologic set

›Relative activity modification

›Avoid provocative neck extension and heavy lifting temporarily

›Early gentle range of motion as tolerated

›Heat or ice trial

›Heat for muscle spasm predominant pain

›Ice for acute flare with inflammation sensation

›Cervical collar limited use

›Short term for severe pain only

›Avoid prolonged immobilization

›NSAID based set

›Ibuprofen oral

›400 mg every 6 to 8 hours as needed

›Maximum 2400 mg per day

›Avoid in CKD, GI bleed risk, anticoagulation high risk

›Naproxen oral

›500 mg initial dose

›250 mg every 12 hours as needed

›Maximum 1000 mg per day

›Ketorolac parenteral

›15 mg IV or IM once

›Avoid repeat dosing in older adults and CKD risk

›Avoid with active GI bleed risk

›Acetaminophen set

›Acetaminophen oral

›1000 mg every 6 to 8 hours as needed

›Maximum 3000 mg per day in most adults

09Special Populations/sp42

Pregnancy

›Diagnostic considerations

›Imaging preference hierarchy

›MRI without gadolinium preferred when urgent imaging needed

›CT only if time critical and benefits outweigh risks

›Alternate diagnoses

›Preeclampsia neurologic symptoms as separate pathway if pregnant with headache or visual change

›Thromboembolic risk context if limb swelling

›Medication considerations

›NSAIDs avoidance in later pregnancy

›Avoid third trimester NSAIDs

›Use acetaminophen as first line

›Neuropathic agents caution

›Risk benefit discussion for gabapentin or pregabalin

›Prefer obstetric and primary care coordination

Geriatric

›Higher risk features

›Lower threshold for imaging with neurologic deficits

›Cervical spondylotic myelopathy more prevalent

›Falls and occult fracture risk higher

›Medication harm reduction

›Avoid or minimize muscle relaxants

›Avoid rapid titration of gabapentinoids

›Dosing and monitoring

›Renal function impact

›Gabapentin dose reduction

›NSAID avoidance in CKD risk

›Delirium and falls risk

10Background/b51

Epidemiology

›Frequency and demographics

›Typical age range

›Peak incidence in middle age

›Degenerative causes increase with age

›Common levels affected

›C6 and C7 roots most frequently involved

›Multilevel degenerative disease common

›Coding and terminology

›ICD-10 cervical radiculopathy

›M54.12

›Cervicobrachial syndrome coding variability by jurisdiction

›SNOMED CT concepts

›Cervical radiculopathy concept

›Cervical disc disorder with radiculopathy concept

Pathophysiology

›Mechanisms

›Disc herniation

›Nucleus pulposus protrusion causing nerve root compression

›Chemical inflammation contributing to pain

›Spondylosis and foraminal stenosis

›Osteophytes narrowing neural foramen

›Facet hypertrophy contributing to compression

›Symptom generation

›Dermatomal pain and paresthesia

›Nerve root irritation pattern

›Overlap between dermatomes common

›Weakness and reflex changes

11Patient Discharge Instructions/pdi22

Copy discharge instructions

›Cervical radiculopathy discharge set

›Expected course

›Pain can flare for days

›Many improve over 2 to 6 weeks with conservative care

›Home care

›Relative activity modification

›Heat or ice 15 to 20 minutes at a time

›Sleep positioning with neutral neck support

›Medications

›Use acetaminophen and NSAID as directed if safe for you

›Avoid driving or alcohol if taking sedating medications

›Follow up

›Primary care or physiotherapy within 1 to 2 weeks

›Earlier review if symptoms worsen

›Return to ED now if any occur

›New or worsening arm or hand weakness

›Trouble walking or new balance problems

›Numbness in both arms or legs

›Loss of bladder or bowel control

›Fever with worsening neck pain

›Severe unrelenting pain at rest

›New chest pain or shortness of breath

12References/r17

Clinical guidelines and evidence sources

›Guideline and review set

›North American Spine Society cervical radiculopathy guideline

›Conservative management as first line in most without red flags

›Imaging reserved for red flags or persistent deficits

›American Academy of Orthopaedic Surgeons neck pain and radiculopathy resources

›Emphasis on activity and physiotherapy

›Surgical referral indications for deficit progression

›Emergency medicine neck trauma imaging rules

›Canadian C spine rule validation literature

›NEXUS criteria validation literature

›Evidence summaries set

›Degenerative cervical spine imaging prevalence studies

›High rates of asymptomatic disc bulge and foraminal narrowing

›Importance of clinicoradiologic correlation

›Neuropathic pain pharmacotherapy evidence

›Gabapentinoids effectiveness modest and variable

›Adverse effect burden and taper planning

Evidence & Review

Evidence & Review