What is the recommended evaluation and management for a 42-year-old female (F) patient who presents with neck and back pain 3 days after an assault, having previously been seen at a minute clinic (urgent care) without undergoing any imaging studies?

Evaluation and Management of Assault-Related Neck and Back Pain

CT imaging of the cervical and thoracic spine is strongly recommended for this 42-year-old female assault victim with persistent neck and back pain to rule out potentially serious injuries that may have been missed during the initial evaluation. 1

Initial Assessment

When evaluating a patient with assault-related neck and back pain, focus on:

• Neurological status: Assess for focal deficits, weakness, numbness, or tingling
• Pain characteristics: Location, radiation, severity, and exacerbating factors
• Red flags: Difficulty walking, bowel/bladder dysfunction, progressive neurological symptoms

Risk Factors for Significant Injury

This patient has several concerning features:

• History of assault (traumatic mechanism)
• Persistent pain 3 days after injury
• Previous evaluation without imaging
• Both neck and back involvement

Imaging Recommendations

For Cervical Spine:

1. CT scan of the cervical spine is the first-line imaging modality for suspected cervical spine trauma 1

   • Superior sensitivity (88.6-100%) compared to radiographs for detecting fractures
   • Can identify vascular injuries and soft tissue damage

2. MRI of the cervical spine should be considered if:

   • Neurological deficits are present
   • CT findings are equivocal
   • Persistent pain despite negative CT 2
   • MRI can detect ligamentous injuries, disc herniations, and spinal cord injuries not visible on CT

For Thoracolumbar Spine:

• CT scan of the thoracic/lumbar spine is recommended for evaluation of back pain following trauma 1
• Consider MRI if neurological symptoms are present or if CT is negative but pain persists

Clinical Pearls and Pitfalls

• Pitfall #1: Relying on absence of immediate neurological deficits. Vascular injuries or unstable ligamentous injuries may present with delayed symptoms.

• Pitfall #2: Underestimating assault-related injuries. Women with assault-related injuries most commonly have injuries to the head and neck region (odds ratio 12.8) 3.

• Pitfall #3: Inadequate follow-up. Assault victims are more likely to leave without completing treatment 3. Ensure proper follow-up is arranged.

Management Algorithm

1. Immediate stabilization:

   • Cervical collar if neck pain is significant or if neurological symptoms are present
   • Pain management with NSAIDs or acetaminophen

2. Imaging:

   • Order CT of cervical and thoracic spine
   • If CT negative but symptoms persist or neurological deficits are present, proceed to MRI

3. Based on imaging results:

   • Normal imaging + mild symptoms: Conservative management with pain control, gentle range of motion exercises, and follow-up
   • Stable fracture: Orthopedic/neurosurgical consultation, appropriate immobilization
   • Unstable fracture or neurological deficit: Immediate neurosurgical consultation

4. Follow-up plan:

   • Arrange follow-up within 1-2 weeks to reassess symptoms
   • Consider physical therapy referral for persistent pain

Remember that neck pain is the fourth leading cause of disability 4, and proper evaluation and management are essential to prevent chronic pain and disability.