565 - Ulnar Neuritis Masquerading as Cervical Radiculitis

Case Diagnosis: Left elbow ulnar neuritis

Case Description: 68-year-old male presented with neck pain and paresthesia radiating into left C8-T1 dermatomes. His symptoms had not responded to physical therapy, chiropractic treatment, or gabapentin. Examination revealed tenderness over the left trapezius, decreased light touch in the C8-T1/ulnar dermatome, and positive left Spurling’s. MRI demonstrated multilevel cervical spondylosis resulting in moderate to severe bilateral foraminal stenosis between C3 and C7 levels. EMG findings suggested left C8 radiculopathy. However, symptoms failed to improve following two cervical steroid injections.

Prior to a possible spine surgical intervention, ultrasound of the left ulnar nerve was performed due to lack of significant C7-T1 pathology on MRI, revealing neuritis of the ulnar nerve at the level of the cubital fossa. MRI showed increased signal in the ulnar nerve with surrounding edema. The patient subsequently underwent ulnar nerve transposition and left AIN to ulnar motor nerve transfer, resulting in complete resolution of his symptoms.

Discussions: Peripheral entrapment neuropathies are commonly thought to present with symptoms distal to the lesion. This patient’s symptoms and EMG findings supported diagnosis of cervical radiculopathy, and given the significant multi-level foraminal stenosis, he would likely have undergone a spine surgery, had we not obtained imaging of his left elbow. What prompted further diagnostic work up in this case was the lack of significant central or foraminal stenosis at the C7-T1 level and his focal symptoms in the C8/T1 dermatomes.

Conclusions: Peripheral entrapment neuropathies may present with more proximal symptoms, which can be misdiagnosed as radiculopathy. In cases of suspected cervical radiculopathy that have not responded to conservative treatment, we recommend ruling out entrapment neuropathies prior to considering surgery.