What is the initial treatment for cervicalgia?

Initial Treatment for Cervicalgia

The initial treatment for cervicalgia (neck pain) should be conservative management with non-operative approaches, as 75-90% of patients achieve symptomatic improvement without surgery. 1

Diagnosis and Assessment

• Cervicalgia is defined as pain in the neck region that may radiate to the shoulders, upper limbs, or back 2
• Distinguish between simple cervicalgia and cervical radiculopathy (which includes radiating arm pain, sensory deficits, or motor dysfunction) 1, 3
• Physical examination should focus on identifying neurological deficits, myelopathic signs, and specific nerve root involvement 4
• The Spurling and shoulder abduction tests are the two most common examinations used to identify cervical radicular pain 4

First-Line Treatment Options

• Physical therapy is recommended as a first-line treatment for cervical pain and has shown promising results at short-term follow-up 5, 1
• Cervical collar may be used for a short period of immobilization (typically not exceeding 1-2 weeks) to provide temporary relief 3, 5
• Medications for pain management:
  • NSAIDs such as ibuprofen (400mg every 4-6 hours as needed) for pain relief 6, 3
  • For neuropathic symptoms, medications such as gabapentin, pregabalin, or tricyclic antidepressants may be considered, though evidence is limited 4

Second-Line Interventions

• Cervical traction may temporarily decompress nerve impingement, though evidence suggests it is no more effective than placebo traction 3, 5
• Selective nerve blocks can target nerve root pain in cases of radiculopathy 3
• Epidural corticosteroid injections may be beneficial for acute and subacute cervical radicular pain, preferably using an interlaminar approach 4

Surgical Considerations

• Surgical intervention should be considered only after failure of conservative treatment 7, 1
• Anterior cervical decompression and fusion (ACDF) may provide more rapid relief (within 3-4 months) of arm/neck pain compared to physical therapy or immobilization 7
• However, at 12-month follow-up, comparable clinical improvements are seen with conservative therapy 7

Treatment Algorithm

1. Initial phase (0-4 weeks):

   • Rest and activity modification
   • Short-term cervical collar use if needed
   • NSAIDs for pain management
   • Begin gentle physical therapy exercises 3, 5

2. Intermediate phase (4-12 weeks):

   • Continue physical therapy with progressive exercises
   • Consider nerve blocks or epidural injections if pain persists 4
   • Evaluate for neuropathic pain and consider appropriate medications 4

3. Advanced phase (>12 weeks):

   • For persistent symptoms, obtain MRI to evaluate for structural causes 7, 1
   • Consider surgical consultation for patients with significant functional deficit or persistent radicular symptoms despite conservative management 7, 1

Important Caveats

• MRI findings must always be correlated with clinical symptoms, as false positives and false negatives are common 1
• The natural course of cervical pain is generally favorable, with most patients improving over time regardless of intervention 5
• Surgical outcomes for relief of arm pain can be good (80-90%), but recurrent symptoms have been reported in up to 30% of patients after certain procedures 1
• Use the lowest effective dose of medications for the shortest duration consistent with treatment goals 6