What is the initial workup and management for a patient presenting with neck pain?

From the Guidelines

The initial workup for neck pain should begin with a thorough history and physical examination to identify red flags that may indicate serious underlying pathology, and most cases can be managed conservatively with over-the-counter analgesics, gentle activity, and ergonomic modifications. These red flags include fever, unexplained weight loss, history of cancer, neurological deficits, trauma, or pain that worsens with rest 1. Most cases of neck pain are mechanical or musculoskeletal in nature and can be managed conservatively. First-line treatment includes over-the-counter analgesics such as acetaminophen (500-1000mg every 6 hours, not exceeding 4g daily) or NSAIDs like ibuprofen (400-600mg three times daily with food) for 1-2 weeks. Muscle relaxants such as cyclobenzaprine (5-10mg three times daily) may be added for significant muscle spasm, though they should be used short-term due to sedation effects. Application of heat or cold therapy for 15-20 minutes several times daily can provide symptomatic relief. Patients should maintain gentle activity as tolerated rather than strict bed rest, which can lead to deconditioning. Imaging is not routinely indicated for acute neck pain unless red flags are present; plain radiographs should be considered first if imaging is necessary, with MRI reserved for cases with neurological symptoms or suspected serious pathology 1.

Some key points to consider in the management of neck pain include:

• Patient education on the generally favorable prognosis of acute neck pain and the importance of remaining active 1
• The use of clinical decision management tools to aid in stratification of care and identification of patients at high risk of chronic disability 1
• The limited role of imaging in the initial evaluation of neck pain, with a focus on identifying red flags and selecting patients who may benefit from advanced imaging such as MRI 1
• The importance of ergonomic modifications at work and home to prevent recurrence, including proper computer monitor height, supportive pillows, and regular position changes during prolonged sitting 1

Physical therapy focusing on gentle stretching, strengthening, and proper posture should be initiated within 2-4 weeks if pain persists, and patients should be educated about self-management options and encouraged to take an active role in their care 1. Overall, a conservative approach to the management of neck pain, with a focus on patient education, self-management, and selective use of imaging and other interventions, is recommended 1.

From the Research

Initial Workup for Neck Pain

• The initial workup for a patient presenting with neck pain involves a thorough history and physical examination to identify the underlying cause of the pain 2.
• The history should include questions about the onset, duration, and characteristics of the pain, as well as any associated symptoms such as numbness, tingling, or weakness.
• The physical examination should include an assessment of the patient's range of motion, strength, and reflexes, as well as a search for any signs of neurological dysfunction.

Diagnostic Imaging

• Diagnostic imaging, such as magnetic resonance imaging (MRI), is not always necessary for patients with neck pain, but may be considered in cases involving focal neurologic symptoms, pain refractory to conventional treatment, or when referring a patient for interventional treatment 2.
• However, it is important to note that MRI may show abnormal findings in asymptomatic individuals, and should be interpreted in the context of the patient's clinical presentation.

Management of Neck Pain

• The management of neck pain depends on the underlying cause of the pain, but may include conservative treatments such as medications, physical therapy, and exercise 3, 4.
• Exercise treatment appears to be beneficial in patients with neck pain, and may include supervised exercise and manual therapy 2, 5.
• Other treatments, such as muscle relaxants, epidural corticosteroid injections, and cervical facet joint radiofrequency denervation, may also be considered in certain cases 2.
• In patients with radiculopathy or myelopathy, surgery may be more effective than nonsurgical therapy in the short term, but not in the long term for most people 2.

Non-Surgical Interventions

• Non-surgical interventions, such as supervised exercise and manual therapy, may be recommended for patients with recent onset neck pain or cervical radiculopathy 5.
• Other non-surgical interventions, such as acupuncture, traction, and oral NSAID or Tramadol, may also be considered in certain cases 5.
• However, it is important to note that the evidence for these interventions is often based on low-quality evidence or consensus, and further research is needed to fully understand their effectiveness.