What are the recommended management options for cervical pain?

Management Options for Cervical Pain

For cervical pain management, a multimodal approach incorporating nonpharmacologic therapies as first-line treatment, followed by appropriate pharmacologic options and interventional procedures for refractory cases is strongly recommended. 1

Initial Assessment and Diagnosis

• MRI with contrast is recommended for evaluating soft tissue structures when symptoms worsen or fail to improve with conservative management 1
• CT may provide better evaluation of bony structures in cases of suspected structural abnormalities 1
• Red flags requiring urgent reassessment include:
  • Development of bladder/bowel dysfunction
  • Rapid progression of weakness
  • Development of bilateral symptoms
  • New gait abnormalities 1

Treatment Algorithm

First-Line: Nonpharmacologic Approaches

1. Physical Therapy and Exercise

   • Cervico-scapular strengthening exercises 2
   • Home exercise programs with stretching and low-intensity isometric contractions 3
   • Self-applied cervical mobilization techniques 4

2. Manual Therapy

   • Therapist-driven cervical manipulation and mobilization 2, 3
   • Thoracic manipulation for acute and subacute neck pain 5
   • Evidence shows combination of manipulation/mobilization with strengthening exercises is most effective for decreasing pain 2

3. Supportive Measures

   • Heat therapy
   • Massage
   • Acupressure 1

Second-Line: Pharmacologic Options

1. NSAIDs

   • Ibuprofen 400-800 mg every 4-6 hours as needed for pain relief 6
   • Use the lowest effective dose for the shortest duration to minimize adverse effects 6

2. Muscle Relaxants

   • For associated muscle spasm 1

3. Avoid Long-term Opioid Use

   • Reserve for severe cases unresponsive to other therapies 1
   • If needed, consider tramadol at lowest effective dose 7

Third-Line: Interventional Procedures

1. For Cervical Radicular Pain

   • Interlaminar cervical epidural corticosteroid administration for subacute cervical radicular pain 8
   • Pulsed radiofrequency treatment adjacent to the cervical dorsal root ganglion for chronic cervical radicular pain 8
   • Conventional radiofrequency treatment when pulsed radiofrequency effect is insufficient 8

2. For Cancer-Related Cervical Pain

   • Cordotomy should be available to patients with otherwise poorly controlled cancer-related pain 9
   • High cervical cordotomy is effective for unilateral cancer-related pain below the C4 dermatomes 9
   • Spinal cord stimulation in selected cases of refractory pain 9

Surgical Considerations

Surgical intervention should be considered if:

• Progressive neurological deficit develops
• Significant symptoms persist despite 6-8 weeks of conservative management
• Development of myelopathic signs 1

Surgical options include:

• Anterior cervical discectomy and fusion (ACDF) for primarily anterior compression
• Posterior decompression for multilevel spondylotic myelopathy with canal stenosis
• Circumferential cervical decompression and fusion for severe cervical myelopathy 1

Follow-up and Monitoring

• Follow-up in 4-6 weeks to assess:
  • Progression of weakness
  • Development of new neurological symptoms
  • Response to conservative management 1

Common Pitfalls and Caveats

• Avoid overreliance on imaging findings alone, as abnormalities may not correlate with the patient's pain 8
• NSAIDs should be used with caution in patients with cardiovascular, renal, or gastrointestinal risk factors 6
• Cervical collar use should be limited to short-term relief as prolonged use can lead to muscle deconditioning 4
• Consider the relationship between pain and alcohol use, as pain severity is positively associated with hazardous drinking patterns 1
• Dehydration from alcohol consumption may reduce intervertebral disc cushioning, potentially increasing pressure on cervical structures 1

By following this structured approach to cervical pain management, clinicians can provide effective care while minimizing risks and optimizing patient outcomes.