What is the next step in the workup for a 32-year-old female with chronic left-sided neck pain and normal laboratory results, including normal Thyroid-Stimulating Hormone (TSH) levels?

From the Guidelines

The next step in the workup for a 32-year-old female with chronic left-sided neck pain and normal laboratory results, including normal TSH, should be a thorough physical examination, including a complete head and neck exam, followed by diagnostic imaging with a cervical spine X-ray and potentially an MRI if neurological symptoms are present or if the X-ray findings are inconclusive. Given the chronic nature of the pain and normal thyroid function, musculoskeletal causes such as cervical strain, myofascial pain syndrome, or cervical disc disease are more likely than thyroid pathology 1.

Key Considerations:

• A complete head and neck examination is crucial, as it may reveal signs of musculoskeletal issues or other abnormalities that could be causing the pain.
• Diagnostic imaging should start with a cervical spine X-ray to assess for any bony abnormalities or misalignments.
• If the X-ray findings are inconclusive or if there are neurological symptoms, an MRI of the cervical spine should be considered to evaluate the soft tissues, including the discs, nerves, and spinal cord.
• Conservative management, including physical therapy focusing on cervical strengthening exercises, proper ergonomics education, and pain management with NSAIDs, can be initiated concurrently with the diagnostic workup.
• If muscle spasm is significant, a short course of muscle relaxants may be beneficial.

Further Evaluation:

• The patient's history and physical examination findings will guide the need for further testing or referral to a specialist.
• Persistent symptoms despite conservative management would warrant referral to a specialist such as a neurologist, orthopedist, or pain management physician for further evaluation and treatment.
• It is essential to consider the patient's overall health and any potential underlying conditions that could be contributing to the neck pain, ensuring a comprehensive approach to diagnosis and treatment 1.

Evidence-Based Practice:

• The approach to diagnosing and managing chronic neck pain should be guided by the most recent and highest-quality evidence available, prioritizing interventions that improve morbidity, mortality, and quality of life 1.
• Regular follow-up and reassessment are crucial to adjust the treatment plan as needed and to ensure that the patient receives optimal care.

From the Research

Step-by-Step Workup for Chronic Left-Sided Neck Pain

Given the patient's complaint of achy left side of neck for a year with normal laboratory results, including normal Thyroid-Stimulating Hormone (TSH) levels, the next steps in the workup would involve:

• Evaluating the patient's neck pain pattern, duration, and associated symptoms to determine the best course of treatment 2
• Assessing the patient's disability and functional impairment using tools such as the Neck Disability Index (NDI) to guide rehabilitation efforts 3
• Considering the role of interlaminar and transforaminal epidural injections in managing chronic radicular pain, although the evidence for transforaminal injections is limited 4
• Examining the patient's posture, movement patterns, and muscle activation to identify potential contributors to chronic neck pain, such as altered motor control and muscle impairment 5

Potential Diagnostic Considerations

The following diagnostic considerations may be relevant:

• Cervical radicular pain: evaluate for disc herniation, spinal stenosis, or other structural abnormalities 4, 2
• Muscle impairment: assess for deficits in deep and superficial cervical flexor muscles, and altered patterns of muscle activation 5
• Postural stability: evaluate the patient's balance and posture, particularly in different head positions, to identify potential challenges to the postural control system 6

Treatment Options

Treatment options may include:

• Exercise interventions: tailored to address specific muscle impairments and promote optimal motor control 5
• Epidural injections: interlaminar or transforaminal, depending on the patient's pain pattern and underlying pathology 4, 2
• Rehabilitation programs: focusing on functional restoration, posture correction, and pain management 3