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

Workup for Neck Nerve Pain

The appropriate workup for neck nerve pain should begin with a focused neurological examination and laboratory tests (ESR/CRP), followed by MRI of the cervical spine without contrast as the primary imaging modality for suspected radiculopathy. 1, 2

Initial Assessment

History - Key Elements to Assess

• Pain characteristics (onset, quality, radiation)
• Neurological symptoms (numbness, tingling, weakness in arms/hands)
• "Red flags" requiring urgent evaluation:
  • Fever
  • Recent S. aureus bloodstream infection
  • History of IV drug use
  • Intractable pain despite therapy
  • Tenderness over vertebral body
  • Neurological deficits
  • Abnormal inflammatory markers (ESR, CRP)
  • Age >50 with vascular disease 1, 2

Physical Examination

• Complete motor and sensory neurological examination 1
• Specific tests for cervical radiculopathy:
  • Spurling test
  • Shoulder abduction test
  • Upper limb tension test 3

Laboratory Testing

• Obtain baseline ESR and CRP in all patients with suspected nerve pain 1
• Two sets of bacterial (aerobic and anaerobic) blood cultures if infection is suspected 1
• Consider fungal blood cultures in patients at risk for fungal infection 1
• Brucella serology in endemic areas 1

Imaging Algorithm

First-Line Imaging

• For uncomplicated neck pain without red flags or neurological symptoms:

  • Plain radiographs of the cervical spine 1

• For suspected radiculopathy or presence of red flags:

  • MRI cervical spine without contrast is the gold standard 1, 2
  • MRI provides superior evaluation of soft tissue abnormalities, nerve compression, and spinal cord 1, 2

Alternative Imaging (when MRI is contraindicated)

• CT scan of the cervical spine without contrast
• Combination spine gallium/Tc99 bone scan
• Positron emission tomography scan 1

Special Considerations

• CT offers superior visualization of bony structures but is less sensitive for nerve compression 2
• MRI with contrast is only indicated when infection, tumor, or post-surgical changes are suspected 1
• CT myelography should be considered when MRI is contraindicated or for surgical planning in complex cases 1

Advanced Diagnostic Procedures

• Image-guided aspiration biopsy is recommended when infection is suspected but not established by blood cultures or serologic tests 1
• Electrodiagnostic testing (EMG/NCS) is not needed if diagnosis is clear but useful when peripheral neuropathy is a possible alternative diagnosis 3

Common Pitfalls to Avoid

1. Overreliance on imaging - MRI frequently shows abnormalities in asymptomatic individuals 2
2. Failure to recognize red flags requiring urgent evaluation 1
3. Performing unnecessary imaging for acute neck pain without neurological symptoms 1
4. Skipping baseline inflammatory markers (ESR/CRP) which are important screening tools 1
5. Performing image-guided biopsy in patients with established S. aureus bloodstream infection (unnecessary) 1

Special Populations

• Patients with neurologic compromise, impending sepsis, or hemodynamic instability require immediate surgical intervention and empiric antimicrobial therapy 1
• For complete evaluation of cranial nerve involvement (CN IX, X, XI, XII), imaging may need to extend into the neck and mid-thorax 1

By following this systematic approach to the workup of neck nerve pain, clinicians can efficiently diagnose the underlying cause and initiate appropriate treatment while avoiding unnecessary testing.