What is the appropriate workup for a patient presenting with neck pain?

Comprehensive Workup for Neck Pain

For patients presenting with neck pain, begin with a focused assessment to categorize the pain into one of four grades, then proceed with appropriate imaging only when indicated by red flags or persistent symptoms despite conservative management. 1

Initial Assessment

History Taking - Key Elements

• Duration and onset: Acute (<6 weeks) vs. chronic
• Pain characteristics: Location, radiation, quality, severity (0-10 scale)
• Aggravating/alleviating factors: Movement, position, activities
• Associated symptoms: Radicular symptoms, weakness, numbness, paresthesias
• Red flags 1, 2:
  • Trauma history
  • History of cancer or unexplained weight loss
  • Fever or signs of infection
  • Progressive neurological deficits
  • Bladder/bowel dysfunction
  • Severe unremitting night pain
  • Prior neck surgery
  • Systemic diseases
  • History of intravenous drug use
  • Intractable pain despite therapy
  • Age >50 with vascular disease risk factors
  • Abnormal laboratory values

Physical Examination

1. Inspection: Posture, alignment, muscle atrophy, skin changes
2. Palpation: Tenderness, muscle spasm, step-offs
3. Range of motion: Active and passive
4. Neurological examination:
   • Motor strength in all myotomes (C5-T1)
   • Sensory testing in all dermatomes
   • Deep tendon reflexes (biceps, brachioradialis, triceps)
   • Pathological reflexes (Hoffman's, Babinski)
   • Upper motor neuron signs (hyperreflexia, clonus)
5. Special tests:
   • Spurling's test (foraminal compression)
   • Shoulder abduction test
   • Valsalva maneuver
   • Lhermitte's sign

Pain Classification System 1

Based on your assessment, categorize neck pain into one of four grades:

Grade	Description	Initial Management
I	No signs of major pathology, minimal interference with daily activities	Conservative management
II	No signs of major pathology but significant interference with daily activities	Conservative management
III	Neurological signs of nerve compression	Consider imaging
IV	Signs of major pathology	Immediate imaging

Diagnostic Testing

Laboratory Studies (when indicated by red flags)

• Complete blood count
• Erythrocyte sedimentation rate
• C-reactive protein
• Rheumatoid factor and anti-CCP antibodies (if inflammatory arthritis suspected)

Imaging Studies

1. Plain Radiographs:

   • Not routinely indicated for Grade I/II neck pain 3, 1
   • Consider for trauma, suspected instability, or when red flags are present
   • Views: AP, lateral, oblique, open-mouth odontoid

2. MRI Cervical Spine:

   • Indicated for 1:
     • Grade III pain (neurological signs of nerve compression)
     • Grade IV pain (signs of major pathology)
     • Symptoms persisting >6-8 weeks despite conservative management
     • Red flags present
   • Non-contrast MRI is usually sufficient; contrast indicated for suspected infection, malignancy, or inflammatory conditions 1

3. CT Scan:

   • Preferred for acute trauma and better bone detail 1
   • Consider when MRI is contraindicated

4. Additional Studies (when indicated):

   • CT myelography: When MRI contraindicated or for surgical planning 3
   • Electromyography/Nerve Conduction Studies: To confirm radiculopathy or differentiate from peripheral neuropathy

Management Algorithm

Grade I and II (Mechanical Neck Pain)

1. Education and reassurance
2. Activity modification while maintaining function
3. Pharmacotherapy:
   • NSAIDs at lowest effective dose for shortest duration 1
   • Muscle relaxants if muscle spasm present
4. Physical interventions:
   • Exercise therapy
   • Mobilization/manipulation
   • Postural correction

Grade III (Radiculopathy)

1. All Grade I/II interventions
2. MRI cervical spine
3. Consider referral to specialist if:
   • Progressive neurological deficits
   • Severe or persistent symptoms
   • Failed conservative management after 6-8 weeks

Grade IV (Major Pathology)

1. Immediate imaging (MRI with appropriate protocol)
2. Urgent specialist referral
3. Management based on underlying pathology

Common Pitfalls to Avoid

• Over-reliance on imaging: MRI shows high rates of abnormalities in asymptomatic individuals 3, 2
• Failure to recognize red flags: Can lead to delayed diagnosis of serious conditions
• Inadequate neurological examination: May miss myelopathy or radiculopathy
• Premature specialty referral: Most acute neck pain resolves within 2 months with conservative management 4
• Focusing only on structural findings: Psychological factors and stress can contribute significantly to neck pain

Remember that nearly 50% of individuals with acute neck pain will continue to experience some degree of pain or frequent occurrences 2, so setting appropriate expectations with patients is crucial.