Physical Examination:

VITALS

• Age: 38
• Height: 5’10”
• Weight: 205lbs
• Temperature: 98.6 F
• Pulse: 60 beats per minute, strong, regular
• BP: 118/78 mmHg seated, bilaterally
• Respiration = 15 breaths/min

The patient is in visible mild discomfort during the history (especially when they turn their head to look at you). Evaluation reveals:

Sensory and motor

• Upper extremity muscle tests are all strong bilaterally
• Biceps and Triceps DTRs are 2+ bilaterally
• Sensory testing is intact and equal in bilateral C5-T1 dermatomes

Orthopedic testing

• Cervical Compression and Bilateral Maximum Cervical Compression makes the local neck pain worse
• Cervical Distraction makes the neck pain feel better
• No additional pain with bilateral Shoulder depression, Bilateral Cervical Kemp’s test, or Valsalva
• Painful and reduced cervical aROM

Palpation

• Mild-moderate pain with static palpation over the C5 facets bilaterally
• Cervical Paraspinal muscles have +1/4 tenderness on the left and +2/4 tenderness on the right
• Painful and reduced cervical aROM
• Cervical Joint Restrictions noted at C1-2, C3-4

Question: Based on the information provided above what is your working diagnosis at this point?

Question: Would you perform and additional imaging studies (X-Ray/C.T./MRI)?