Differential Diagnosis for Neck Pain

The patient presents with neck pain that started 4 days ago and has worsened, located on the right back side and deep within, not alleviated by positioning or ice. Here's a categorized differential diagnosis:

• Single Most Likely Diagnosis
  • Musculoskeletal Strain: This is the most common cause of neck pain, often resulting from poor posture, muscle overuse, or minor injuries. The acute onset and location of the pain, as well as the lack of systemic symptoms, support this diagnosis.
• Other Likely Diagnoses
  • Cervical Spondylosis: A condition involving wear and tear on the disks in the neck, which can cause pain and stiffness. Given the patient's age, this might be less likely but still possible, especially if there's a history of similar episodes or chronic neck issues.
  • Herniated Cervical Disk: This occurs when the soft inner gel of the disk leaks out through a tear or crack in the outer layer, potentially irritating nearby nerves and causing pain. The deep and worsening nature of the pain could suggest nerve involvement.
  • Tension Headache: While primarily causing head pain, tension headaches can also cause neck pain. The pain is usually bilateral but can be unilateral and is often described as a band or a squeezing sensation around the forehead, back of the neck, or both.
• Do Not Miss Diagnoses
  • Cervical Spine Fracture: Although less likely without a history of trauma, a fracture must be considered, especially if the pain is severe and there's any history of a fall or accident.
  • Spinal Epidural Abscess: A rare but serious condition that requires immediate medical attention. Symptoms can include severe neck pain, fever, and neurological deficits.
  • Meningitis: Inflammation of the protective membranes covering the brain and spinal cord, known as the meninges. This condition is medical emergency and can present with severe headache, fever, and stiff neck.
• Rare Diagnoses
  • Cervical Spinal Stenosis: Narrowing of the spinal canal in the neck, which can cause pain, numbness, or weakness in the neck, arms, or legs. This condition is more common in older adults.
  • Multiple Myeloma or Metastatic Cancer: Although rare, cancer can cause neck pain, especially if it involves the spine. This would be more likely in patients with a known history of cancer or other systemic symptoms.
  • Temporal Arteritis (Giant Cell Arteritis): An inflammation of the arteries that can cause neck pain, usually accompanied by other symptoms like headache, visual disturbances, and jaw claudication. This condition is more common in older adults.

Patient Workup

The workup should include:

• A thorough history to identify any precipitating factors, trauma, or systemic symptoms.
• A physical examination focusing on the neck, including range of motion, palpation for tenderness, and a neurological examination to assess for any deficits.
• Imaging studies such as X-rays, CT, or MRI of the cervical spine, depending on the clinical suspicion and findings.
• Laboratory tests if an infectious or inflammatory cause is suspected, such as complete blood count (CBC), erythrocyte sedimentation rate (ESR), or C-reactive protein (CRP).
• Consideration for immediate referral or further evaluation if any "Do Not Miss" diagnoses are suspected.