What is the appropriate workup for a pregnant patient presenting to the emergency department (ED) with neck pain and stiffness without fever?

Emergency Department Workup for Pregnant Patient with Neck Pain and Stiffness Without Fever

A pregnant patient presenting to the emergency department with neck pain and stiffness without fever should undergo a focused neurological examination and appropriate imaging based on clinical suspicion, with MRI being the preferred imaging modality if serious pathology is suspected.

Initial Assessment

• Assess vital signs including blood pressure to evaluate for pregnancy-related hypertensive disorders that may present with neck pain and headache 1
• Document presence or absence of headache, altered mental status, neck stiffness, fever, rash, seizures, and signs of shock 2
• Evaluate for "red flag" symptoms including radicular pain, sensory deficits, or motor weakness that may indicate cervical radiculopathy or more serious pathology 2
• Note that Kernig's sign and Brudzinski's sign should not be relied upon for diagnosis of meningitis 2

Differential Diagnosis

• Consider common causes of neck pain in pregnancy:
  • Musculoskeletal strain (most common) 3
  • Cervical radiculopathy 2
  • Meningitis (less likely without fever, but should be considered) 2
  • Preeclampsia with severe features (can present with neck pain and headache) 1
  • Pregnancy-related postural changes 4

Diagnostic Approach

• For patients with isolated neck pain and stiffness without neurological deficits or other concerning symptoms:

  • Cervical spine radiographs may be considered as initial imaging if indicated, though they have limited utility in the absence of trauma 2
  • Physical examination findings alone have limited accuracy for diagnosing serious cervical pathology 2

• For patients with concerning neurological symptoms or "red flags":

  • MRI cervical spine without contrast is the preferred imaging modality during pregnancy 2, 5
  • CT should be reserved for emergent situations when MRI is not immediately available, as radiation exposure poses minimal but present risk to the fetus 5

• For suspected meningitis (though less likely without fever):

  • Lumbar puncture should be considered if clinical suspicion exists despite absence of fever 2
  • Neuroimaging should precede lumbar puncture if there are focal neurologic deficits or altered mental status 2

Special Considerations in Pregnancy

• Pregnant women frequently use complementary and alternative medicine for neck pain (39.9% consult massage therapists), which should be documented in the history 4
• Neurologic complaints in pregnancy require heightened vigilance as missed diagnoses can have devastating consequences 6
• A normal neurological examination does not adequately exclude serious intracranial pathology in pregnant patients 6
• Non-contrast MRI is generally considered safe in pregnancy and is preferred over CT when available 5
• If CT is necessary in emergent situations, it should not be withheld due to exaggerated concerns about radiation, as the risks of missing serious pathology typically outweigh the minimal radiation risk 5

Management Considerations

• Consultation with obstetrics is recommended for pregnant patients with significant neurological symptoms 1, 7
• Early and aggressive intervention for neurologic events during pregnancy is critical to maternal and fetal outcomes 7
• For patients with suspected musculoskeletal neck pain, conservative management may be appropriate with close follow-up 3
• For patients with suspected meningitis despite absence of fever, empiric antibiotics may be considered while awaiting diagnostic results 2

Common Pitfalls to Avoid

• Delaying appropriate imaging in pregnant patients with concerning neurological symptoms due to radiation concerns 5
• Relying solely on the absence of fever to rule out meningitis 2
• Assuming neck pain in pregnancy is always musculoskeletal in nature 6
• Failing to consider preeclampsia in pregnant patients with neck pain and headache 1