What is the initial management for a 48-year-old female patient presenting to the emergency room (ER) with neck pain and stable vital signs, with no significant past medical history (PMH)?

Initial Management of Neck Pain in a 48-Year-Old Female

For a 48-year-old female presenting to the ER with neck pain and stable vital signs without significant past medical history, a detailed clinical history and physical examination is frequently all that is needed for initial assessment and management, without immediate imaging. 1

Assessment Algorithm

Step 1: Screen for "Red Flags"

• Assess for signs of serious underlying pathology that would warrant immediate investigation 1:
  • Risk factors for fracture (trauma, osteoporosis)
  • Signs of malignancy (unexplained weight loss, history of cancer)
  • Constitutional symptoms (fever, weight loss)
  • Signs of infection or risk factors (immunosuppression, IV drug use)
  • Inflammatory arthritis
  • Vascular etiology suspected
  • Neurological deficits or spinal cord injury
  • Coagulopathy
  • Elevated inflammatory markers (WBC, ESR, CRP)

Step 2: Grade the Neck Pain

• Grade I: Neck pain with no signs of major pathology and minimal interference with daily activities 2
• Grade II: Neck pain with no signs of major pathology but significant interference with daily activities 2
• Grade III: Neck pain with neurologic signs of nerve compression (radiculopathy) 2
• Grade IV: Neck pain with signs of major pathology 2

Step 3: Physical Examination

• Evaluate range of motion 3
• Assess for tenderness to palpation 1
• Perform neurological examination to rule out radiculopathy or myelopathy 1
• Examine for any neck masses or lymphadenopathy 1

Management Recommendations

For Grade I or II Neck Pain (Most Common Scenario)

• First-line pharmacologic treatment 4:

  • Acetaminophen
  • NSAIDs or COX-2 inhibitors
  • Short-term muscle relaxants if muscle spasm is present

• Non-pharmacologic interventions 2:

  • Exercise therapy
  • Mobilization
  • Heat or cold therapy
  • Gentle stretching

For Grade III (Radiculopathy)

• Consider MRI if symptoms persist beyond 4-6 weeks 4
• May benefit from referral to physical medicine and rehabilitation 5
• Consider epidural steroid injections for persistent symptoms 6, 4

For Grade IV (Major Pathology)

• Immediate appropriate imaging and specialist referral 2
• Management specific to diagnosed pathology 2

Important Considerations

• Acute neck pain typically resolves within 2 months with or without treatment 5
• Nearly 50% of individuals may continue to experience some degree of pain or frequent recurrences 6
• Early consultation with a physical medicine and rehabilitation spine specialist (within 10 days) may decrease the rate of surgical interventions 5
• Imaging is not recommended for initial management unless red flags are present 1
• MRI has a high rate of abnormal findings in asymptomatic individuals and should be reserved for cases with focal neurologic symptoms or pain refractory to conventional treatment 6

Follow-up Recommendations

• If symptoms have not resolved in 4-6 weeks, re-evaluation and additional workup should be considered 4
• Persistent symptoms may require imaging and specialist referral 6

Common Pitfalls to Avoid

• Ordering unnecessary imaging studies in the absence of red flags 1
• Failure to identify serious underlying pathology by missing red flags 3
• Overreliance on imaging findings that may not correlate with clinical symptoms 1, 6
• Inadequate follow-up for persistent symptoms 4