A Case of Acute Cervical Pain with Radicular and Coincidental Distal Joint Symptoms

Case at a Glance

A 40-year-old male presented with acute left-sided neck pain radiating to the arm following a postural strain. This was followed by the seemingly unrelated onset of pain and swelling in his left big toe and pain in his left thumb, prompting an investigation into whether these disparate symptoms could be linked.

Patient's Story

It started after I used a very stiff cushion to recline, which put my neck in a really awkward position for some time. A few days later, the back-left side of my neck began to hurt. That pain then started to travel down into my left upper arm. The most confusing part started a couple of days after that, when the main joint of my left big toe became slightly swollen and painful enough to make me limp. I decided to check my left thumb, and while it doesn't hurt on its own, it is quite painful if I pull it backwards. I'm trying to understand if that one instance of bad posture could have caused this chain reaction of symptoms.

Initial Assessment

The patient, a 40-year-old male, presented with a chief complaint of neck, arm, thumb, and toe pain. The history began approximately one week prior after an incident of sustained poor posture involving cervical flexion. Symptoms began with left posterior neck pain, which progressed to include radiating pain into the left upper arm, classic for cervical radiculopathy. Several days later, he developed new symptoms: acute pain and mild edema of the left first metatarsophalangeal (MTP) joint, and pain on passive extension of the left thumb. The patient reported no specific trauma to the foot or hand and denied systemic symptoms such as fever or rash.

The Diagnostic Journey

The clinical presentation suggested two distinct, likely concurrent, pathologies. The neck and arm pain, along with the thumb pain elicited by movement, were highly suggestive of C6 cervical radiculopathy. The C6 nerve root supplies sensation to the thumb and motor function to muscles in the arm and forearm. A physical examination would focus on a neurological assessment of the upper extremities, including reflex, motor, and sensory testing, as well as provocative maneuvers like the Spurling's test to replicate the radicular pain. The acute monoarthritis of the first MTP joint, however, is not a recognized symptom of cervical spine pathology. Its presentation is classic for podagra, an initial manifestation of gout. This raised the differential diagnosis for the toe pain to include gout, pseudogout, or septic arthritis. The diagnostic plan was therefore twofold: assess the cervical spine clinically for radiculopathy, and investigate the MTP joint inflammation, primarily with a serum uric acid level test.

Final Diagnosis

The final working diagnosis was Acute Left C6 Cervical Radiculopathy, likely secondary to nerve root inflammation from the postural strain, coexisting with an unrelated, coincidental first episode of Acute Gouty Arthritis (Podagra). While the temporal proximity led the patient to suspect a single cause, the distinct clinical nature of the symptoms pointed to two separate conditions.

Treatment Plan

A bifurcated treatment plan was initiated. For the cervical radiculopathy, a conservative management approach was recommended, consisting of a course of NSAIDs (e.g., ibuprofen or naproxen), referral to physical therapy for cervical mobility and strengthening exercises, and education on proper ergonomics. For the acute gout flare in the toe, a short course of a potent NSAID or colchicine was prescribed to reduce inflammation and pain. The patient was also advised on dietary modifications (e.g., limiting purine-rich foods and alcohol) pending the results of his serum uric acid test.

Outcome and Follow-up

The patient was scheduled for a follow-up in two weeks to evaluate the response to treatment. The plan included monitoring the resolution of both the radicular symptoms and the joint inflammation. If cervical symptoms failed to improve, an MRI of the cervical spine would be considered. Long-term management of his newly diagnosed gout would be determined based on his uric acid levels and risk of future flares, potentially involving urate-lowering therapy under the guidance of his primary care physician.