What is the initial approach to a patient presenting with neck pain in the emergency room?

Initial Approach to Neck Pain in the Emergency Room

In patients presenting with neck pain in the emergency room, initial assessment should focus on identifying red flags that warrant immediate investigation, including trauma, malignancy, infection, neurological deficits, and vascular concerns. 1, 2

Triage Assessment

• Patients with neck pain should be triaged into four grades according to severity 3:

  • Grade I: No signs of major pathology and little/no interference with daily activities
  • Grade II: No signs of major pathology but interference with daily activities
  • Grade III: Neurologic signs of nerve compression
  • Grade IV: Signs of major pathology

• Screen for the following red flags that necessitate immediate investigation 1:

  • Trauma history
  • Malignancy risk factors (history of cancer, unexplained weight loss)
  • Constitutional symptoms (fever, weight loss)
  • Infection or increased risk (immunosuppression, IV drug use)
  • Inflammatory arthritis
  • Suspected vascular etiology
  • Spinal cord injury or neurological deficits
  • Coagulopathy
  • Elevated inflammatory markers (WBC, ESR, CRP)
  • Age >50 with concomitant vascular disease
  • Intractable pain despite therapy
  • Tenderness to palpation over a vertebral body

Physical Examination

• Perform a detailed physical examination including 2, 4:

  • Range of motion assessment
  • Palpation for tenderness
  • Neurological examination for radiculopathy or myelopathy
  • Assessment for neck masses or lymphadenopathy

• The manual provocation test for cervical radiculopathy has high positive predictive value 5

Imaging Decisions

• If no red flags are present, imaging is not recommended for initial management 1, 2

• For patients with suspected fracture after trauma, triage should be based on the NEXUS criteria or Canadian C-spine rule 3

• If red flags are present, appropriate imaging should be selected based on specific concerns 1:

  • Plain radiographs: Useful for initial assessment of spondylosis, degenerative disc disease, malalignment, or spinal canal stenosis 1
  • CT: Superior for depicting cortical bone and more sensitive than radiographs for assessing facet degenerative disease, osteophyte formation, and joint abnormalities 1
  • MRI: Most sensitive for soft tissue abnormalities but has high rates of abnormal findings in asymptomatic individuals; reserve for cases with focal neurologic symptoms or pain refractory to conventional treatment 1, 4

Management Considerations

• For Grade I and Grade II neck pain (common neck pain), consider noninvasive treatments for short-term relief 3:

  • Exercises
  • Mobilization
  • Manipulation
  • Analgesics
  • Acupuncture
  • Low-level laser therapy

• For Grade III with persistent radicular symptoms, consider 3, 4:

  • Corticosteroid injections
  • Surgical referral if symptoms persist

• For confirmed Grade IV neck pain, management should be specific to the diagnosed pathology 3

Common Pitfalls to Avoid

• Ordering unnecessary imaging studies in the absence of red flags, as this rarely changes management in acute, uncomplicated neck pain 2, 1

• Overreliance on imaging findings that may not correlate with clinical symptoms, as degenerative changes are common in asymptomatic individuals over 50 years of age 2, 4

• Failing to recognize that MRI has a high rate of abnormal findings in asymptomatic individuals and should not be used as a first-line imaging modality in uncomplicated neck pain 1