What is the appropriate outpatient approach for a 12-year-old (yo) male with no medical history presenting with 3 days of neck pain on the right side?

Outpatient Approach for 12-Year-Old Male with Right-Sided Neck Pain

For a 12-year-old male with no medical history presenting with 3 days of right-sided neck pain, conservative management is recommended without imaging, unless red flags are present. 1

Initial Assessment

• Evaluate for red flags that would warrant immediate investigation, including:

  • Trauma history
  • Constitutional symptoms (fever, weight loss)
  • Signs of infection
  • Neurological deficits
  • Inflammatory markers (if clinically indicated)
  • Vascular etiology concerns 2, 1

• Perform a thorough physical examination to assess:

  • Range of motion
  • Tenderness to palpation
  • Neurological examination to rule out radiculopathy or myelopathy
  • Presence of neck masses or lymphadenopathy 1, 3

Management Algorithm

1. If no red flags are present:

   • Recommend conservative management:
     • Age-appropriate over-the-counter analgesics (acetaminophen or NSAIDs) 4, 5
     • Rest and activity modification 1
     • Gentle stretching exercises 5, 6
     • Application of heat or cold 5
     • Reassurance that most acute neck pain resolves within 2 months 4

2. If red flags are present:

   • Consider appropriate imaging based on specific concerns:
     • MRI is the preferred modality for suspected soft tissue abnormalities, infection, or inflammatory processes 2, 7
     • Plain radiographs may be considered if there is concern for structural abnormalities 2, 7

Follow-up Recommendations

• For uncomplicated neck pain:

  • Follow up in 2-4 weeks if symptoms persist 1
  • Consider physical therapy referral if pain persists beyond 2-4 weeks 4, 6

• For concerning symptoms or red flags:

  • Earlier follow-up or specialist referral as indicated by findings 7
  • Consider repeat evaluation if symptoms worsen or new symptoms develop 1

Important Considerations

• Avoid unnecessary imaging in the absence of red flags, as this rarely changes management in acute, uncomplicated neck pain 2, 1
• Most episodes of acute neck pain will resolve with or without treatment, but nearly 50% of individuals may experience some degree of recurrence 5
• Exercise treatment appears to be beneficial in patients with neck pain 5, 6

Common Pitfalls to Avoid

• Ordering unnecessary imaging studies in the absence of red flags 1
• Overreliance on imaging findings that may not correlate with clinical symptoms 1, 5
• Failure to recognize signs of serious underlying pathology requiring urgent evaluation 3, 8