From the Guidelines
The initial workup for acute on chronic neck pain should prioritize a thorough history and physical examination to identify red flags, followed by conservative management with relative rest, activity modification, and over-the-counter analgesics, reserving imaging and specialist referral for cases with severe pain, radicular symptoms, or red flags. When evaluating a patient with acute on chronic neck pain, it is crucial to consider the potential causes and the most appropriate initial steps for management. The patient's history and physical examination are key components in identifying red flags that may indicate serious underlying pathology, such as trauma, malignancy, or infection 1.
Initial Management
- Conservative management is the recommended initial approach for most patients with acute on chronic neck pain, including relative rest, activity modification, and the use of over-the-counter analgesics like acetaminophen or NSAIDs 1.
- Physical therapy focusing on gentle stretching, postural correction, and strengthening exercises should be initiated within 1-2 weeks to address mechanical factors and promote recovery.
- For patients with moderate to severe pain, short-term muscle relaxants such as cyclobenzaprine may be considered for 7-10 days to help manage pain and discomfort.
Imaging and Specialist Referral
- Imaging is not always necessary at the initial presentation, especially in the absence of red flags or severe symptoms 1. However, if pain is severe, accompanied by radicular symptoms, or if there are concerns about underlying serious pathology, referral for imaging (preferably MRI) and specialist evaluation should be considered.
Patient Education
- Patients should be educated on proper ergonomics, sleep positioning with a supportive pillow, and stress management techniques to address both pain management and underlying mechanical factors, aiming to avoid unnecessary imaging or medication dependence in most cases.
By prioritizing a thorough initial assessment and conservative management, while reserving imaging and specialist referral for appropriate cases, healthcare providers can effectively manage acute on chronic neck pain, minimizing morbidity, mortality, and improving quality of life for patients.
From the Research
Initial Workup for Acute on Chronic Neck Pain
- The initial workup for a patient with acute on chronic neck pain should include determining the presence of radiculopathy or myelopathy, as well as identifying any "red flags" that may signify serious pathology, such as myelopathy, atlantoaxial subluxation, and metastases 2, 3.
- A thorough history and physical examination can provide important clues as to whether the pain is neuropathic or mechanical, and can help identify the underlying cause of the pain 2, 3, 4.
- Diagnostic imaging, such as magnetic resonance imaging (MRI), should be considered for cases involving focal neurologic symptoms, pain refractory to conventional treatment, and when referring a patient for interventional treatment 3, 4.
Management of Acute on Chronic Neck Pain
- The management of acute on chronic neck pain typically involves a combination of pharmacological and non-pharmacological interventions, including:
- Nonsteroidal anti-inflammatory drugs (NSAIDs) and muscle relaxants for acute neck pain 5, 2, 4.
- Exercise treatment, which appears to be beneficial in patients with neck pain 5, 3.
- Physical modalities, such as physical therapy and traction, which can be helpful for some patients 2, 4.
- Alternative treatments, such as massage, acupuncture, and spinal manipulation, which may be considered for patients who do not respond to conventional treatment 5.
- For patients with radiculopathy or myelopathy, surgery may be considered, although it is typically more effective in the short term than in the long term 5, 3.
- A simple pharmacological management protocol, followed by cervical medial branch block (MBB) if necessary, may be effective in managing chronic neck pain, although patients with straight or sigmoid lateral curvature may require more aggressive treatment 6.