The Symptoms Had Resolved—Why Did I Still Recommend an MRI?

Follow Dr Win Huang’s Clinical Reasoning (26)

By Dr Win Huang, PhD (Chinese Medicine & Acupuncture)

Recently, I treated a man in his forties who had worked at a computer for many years. About one week earlier, he woke with sudden neck pain and restricted movement. The pain extended from the neck and shoulder into the right arm, with discomfort through the forearm. The most noticeable neurological symptom was numbness in the right thumb, with milder numbness in the index finger.

He initially thought it was simply a stiff neck after sleeping awkwardly. From the beginning, however, I did not think the case could be understood as an ordinary stiff neck.

Why Did I First Consider the Scalenes and Brachial Plexus?

At the first examination, his neck and shoulder muscles were very tight, particularly around the scalenes. Pressure between the anterior and middle scalene muscles, where the brachial plexus passes, clearly reproduced his familiar shoulder and arm pain and finger numbness.

This showed that the area was mechanically sensitive. Scalene tension and irritation along the brachial plexus were contributing to his symptoms, so my initial treatment focused on the scalenes and surrounding neck and shoulder soft tissues.

His response was clear. Neck movement improved, and pain in the upper back, neck and shoulder decreased. One symptom, however, did not improve to the same degree: numbness in the right thumb remained obvious.

That made me reconsider the original explanation. Was this really only scalene tension and brachial plexus irritation?

Why Did I Become More Suspicious of a Nerve Root Problem?

Further questioning revealed several important details.

First, coughing clearly aggravated the pain and numbness through the arm. Symptoms provoked by coughing, sneezing or straining can be an important clue that a nerve root is irritated.

Second, the sensory distribution was quite focused. Numbness was strongest in the thumb, milder in the index finger and present to some degree along the lateral forearm. This was more consistent with a C6 nerve root pattern.

Third, neurological examination provided an objective finding. The biceps reflex was similar on both sides, but the right brachioradialis reflex was reduced. No clear muscle weakness was detected at that stage.

The patient therefore had more than a subjective feeling of numbness. He had a neurological sign that could be found on examination. When the history, sensory distribution and reflex change were considered together, irritation of the right C6 nerve root became the more likely primary problem.

Why Did Pressure over the Scalenes Still Reproduce the Numbness?

This is where the case could easily become confusing.

If the main problem involved the nerve root, why could pressure over the scalenes and brachial plexus also reproduce the symptoms?

The neural pathway is continuous. After leaving the cervical spine, the nerve roots enter the brachial plexus and later form the peripheral nerves. If a nerve root is irritated, mechanical sensitivity may increase along a larger part of the neural pathway.

The principal problem may therefore be at the cervical spine, while pressure farther along the pathway—around the scalene interval, supraclavicular region or a peripheral nerve—still reproduces the patient’s familiar symptoms.

Reproducing symptoms at one location does not automatically prove that the main lesion is located there. It tells us that the neural pathway is sensitive at that point.

That is why I did not diagnose thoracic outlet syndrome or a scalene syndrome simply because pressure over the scalene region was positive.

Distinguishing a Nerve Root Pattern from a Brachial Plexus Pattern

A relatively typical nerve root disorder often produces a recognisable root pattern. C6 irritation, for example, may cause altered sensation along the radial forearm and around the thumb, sometimes accompanied by corresponding changes in reflexes or muscle strength.

Brachial plexus irritation, particularly around the thoracic outlet or scalene interval, may be more likely to cross several peripheral nerve distributions. Farther along its course, the plexus divides into nerves including the median, ulnar and radial nerves.

Clinically, I therefore ask whether the patient has formed a relatively clear single-root pattern or whether the symptoms involve several nerves and several regions.

This patient’s findings were much closer to a C6 nerve root pattern. That did not exclude coexisting scalene tension or mechanical sensitivity around the brachial plexus. The important task was to distinguish the primary problem from the associated findings.

Could a Negative Spurling Test Exclude Radiculopathy?

Another interesting finding was that his Spurling test was negative. Cervical extension, side-bending and axial compression did not clearly reproduce his radiating arm pain or numbness.

If we looked only at this result, we might hesitate to consider a nerve root problem. Clinical diagnosis, however, cannot be based on one test alone.

The patient had a characteristic sensory distribution, symptoms aggravated by coughing, a reduced right brachioradialis reflex and a clear history of acute neck, shoulder and arm pain. Together, these findings carried more weight than one negative Spurling test.

A clinical diagnosis does not require every test to be positive. What matters is whether the different pieces of evidence point in the same direction.

If the Symptoms Had Resolved, Why Did I Still Recommend an MRI?

After several treatments, the patient was almost free from pain and numbness. Judging only by the result of treatment, the problem appeared to have been resolved.

I still recommended that he return to his GP for further assessment and discuss cervical MRI and specialist review. He had experienced a reasonably clear pattern of nerve root irritation, and the cause still needed to be understood.

Was it temporary inflammatory irritation around the nerve root? Was there a cervical disc protrusion? Was the neural foramen narrowed? Was there structural compression corresponding with the clinical findings?

The answers could have practical implications for his future work, exercise and prevention of recurrence.

If MRI showed no significant structural problem and his symptoms remained fully resolved, he might return to normal activity with less concern. If imaging showed a disc protrusion or nerve root compression corresponding with the clinical pattern, his training, working posture, prevention strategy and future medical management might need to be more specific.

Some episodes of nerve root irritation recover naturally or respond well to conservative care. Continuing or progressive neurological dysfunction, however, may require further medical assessment and intervention.

Clarifying the diagnosis can therefore change what happens next.

Effective Treatment Does Not Mean the Diagnosis Is Complete

The patient’s early improvement after releasing the scalene region showed that the scalenes and surrounding soft tissues contributed to his symptoms. It did not prove that the primary problem originated there.

The sensory distribution, cough-provoked symptoms and reflex change later redirected my attention towards the C6 nerve root.

A clinician should not ask only whether treatment worked. We should continue asking whether the original explanation was complete, where the principal problem was located, why it occurred and what the patient may need to consider in the future.

The patient’s GP was supportive and arranged specialist assessment, with MRI expected within the following weeks. The clinical history, examination and imaging findings could then be considered together.

That is a more complete diagnostic process.

The difficult part of clinical reasoning is often not finding a single positive point. It is deciding, among positive findings, negative tests, treatment responses and imaging results, which finding represents the primary problem and which is secondary.

This patient was no longer in pain and no longer numb, but he still needed to understand what may have happened in his cervical spine and how to approach future work, exercise and possible recurrence.

Clinical care should not look only at whether the patient is better. We should also try to understand why the problem happened.

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Has Your Neck and Arm Pain Improved but the Cause Remains Unclear?

Neck pain accompanied by radiating arm pain, finger numbness or reflex changes may involve the cervical spine, nerve roots, brachial plexus and surrounding soft tissues. Improvement is important, but it does not always explain the original cause.

At PhD Win Acupuncture Clinic, we assess the history, sensory distribution, neurological findings and response to treatment, and advise when GP, imaging or specialist assessment may be appropriate.

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English Disclaimer

This article is based on a clinical case and shares general clinical reasoning and health information. Some non-essential details may have been adjusted to protect patient privacy. It does not replace individual medical assessment, neurological examination, imaging or diagnosis.

The C6 nerve root interpretation described here was a clinical suspicion based on the history, examination and treatment response. It requires correlation with further medical assessment and imaging. Symptom improvement after treatment does not, by itself, confirm the location or structural cause of a disorder.