What is the appropriate assessment and management for a patient presenting with neck pain?

Assessment and Management of Neck Pain

For patients presenting with neck pain, radiographic imaging is not recommended as the initial approach unless red flags are present, as most cases will resolve with conservative management within 2 months. 1, 2

Initial Assessment

• Perform a focused history to identify potential red flags including:

  • Trauma history
  • Neurological symptoms (radiculopathy, myelopathy)
  • Constitutional symptoms (fever, weight loss)
  • History of cancer
  • Immunosuppression
  • Elevated inflammatory markers 3, 4

• Physical examination should assess:

  • Range of motion
  • Neurological function (motor strength, sensory changes, reflexes)
  • Pain patterns (mechanical vs. neuropathic)
  • Signs of myelopathy (Hoffman's sign, hyperreflexia)
  • Provocative tests for radiculopathy 1, 4

Red Flags Requiring Immediate Attention

• Progressive neurological deficits
• Fever with neck pain
• Recent history of infection
• Elevated inflammatory markers (e.g., CRP)
• History of cancer
• Immunosuppression
• Severe, unremitting pain unresponsive to conservative measures 3, 5

Imaging Recommendations

• For uncomplicated neck pain without red flags:

  • Imaging is not recommended initially as degenerative findings correlate poorly with symptoms 6
  • Radiographs are often the first imaging modality if imaging is deemed necessary, but have limited diagnostic value 6

• For neck pain with red flags or neurological symptoms:

  • MRI cervical spine without contrast is the preferred imaging modality 6, 3
  • CT may be considered when bony abnormalities are suspected 6

• For suspected cervical radiculopathy:

  • MRI without contrast is the imaging study of choice 6
  • CT myelography should be reserved for patients who cannot undergo MRI 6

Management Approach

For Acute Neck Pain Without Red Flags:

• Conservative management for 4-6 weeks:
  • Activity modification (avoid prolonged positions)
  • NSAIDs for pain control
  • Physical therapy focusing on gentle stretching and strengthening
  • Heat or cold therapy as tolerated 1, 2

For Chronic Neck Pain (>3 months):

• Continued physical therapy with focus on strengthening and posture correction
• Consider referral to pain management if symptoms persist
• Imaging may be considered if symptoms persist despite conservative management
• Avoid opioids for long-term management 1, 2

For Neck Pain with Radiculopathy:

• Conservative management as first-line approach
• Consider epidural steroid injections for persistent radicular symptoms
• Surgical consultation if symptoms persist >6-12 weeks despite conservative management or with progressive neurological deficits 1, 6

Special Considerations

• Consider referred pain from other sources, such as shoulder impingement, which can present as neck pain near the superomedial aspect of the scapula 7
• Provocative injections for diagnosis of pain generators (e.g., facet blocks) remain controversial with limited evidence supporting their use 6
• SPECT/CT imaging may have a role in identifying pain generators in chronic neck pain when other imaging is equivocal 6

Follow-up Recommendations

• Most acute neck pain resolves within 2 months with or without treatment 1, 2
• If symptoms persist beyond 4-6 weeks despite conservative management, consider:
  • Reassessment for missed red flags
  • Imaging if not previously obtained
  • Specialist referral (neurosurgery, orthopedic surgery, or pain management) 1, 4