From the Guidelines
When approaching a patient with cervical pain, begin with a thorough history and physical examination to determine the cause, which could range from muscle strain to more serious conditions like disc herniation or spinal stenosis, as recommended by the American College of Radiology 1. Initial management typically includes conservative measures such as:
- Recommending rest for 24-48 hours
- Applying ice for the first 48-72 hours (20 minutes on, 20 minutes off), followed by heat therapy
- Prescribing appropriate analgesics based on pain severity:
- Acetaminophen 500-1000mg every 6 hours
- NSAIDs like ibuprofen 400-800mg three times daily with food for 5-7 days
- Muscle relaxants such as cyclobenzaprine 5-10mg at bedtime for severe cases Physical therapy focusing on gentle stretching, strengthening exercises, and proper posture should be initiated after acute pain subsides. Educate patients on ergonomic modifications at work and home, and recommend a cervical pillow for sleep. Red flags requiring immediate attention include severe trauma, fever, unexplained weight loss, neurological deficits, or pain unresponsive to conservative treatment, as these symptoms may indicate infection, malignancy, or significant nerve compression requiring advanced imaging and specialist referral 1.
In terms of imaging, radiographs are appropriate as initial imaging for cervical or neck pain in the absence of “red flag” symptoms or if there are unchanging chronic symptoms, while noncontrast MRI is usually appropriate for assessment of new or increasing radiculopathy due to improved nerve root definition 1. It is essential to consider the patient's medical history and the presence of red flags to accurately guide imaging and treatment, as the diagnostic accuracy of red flag symptoms is not validated for the cervical spine 1.
By following this approach, patients with cervical pain can receive appropriate management and treatment, addressing pain through multiple mechanisms while allowing the body's natural healing processes to occur, and ultimately reducing morbidity, mortality, and improving quality of life.
From the Research
Approach to a Patient with Cervical (Neck) Pain
The approach to a patient with cervical (neck) pain involves a variety of conservative treatments, including medications, physical therapy, and exercise 2. The goal of treatment is to alleviate pain, improve function, and enhance quality of life.
Conservative Treatments
- Physiotherapy: Use of a collar and physiotherapy show promising results at short-term follow-up 3.
- Exercise: Supervised exercise and manual therapy are recommended for non-specific neck pain and cervical radiculopathy 4.
- Medications: Oral NSAID and Tramadol may be considered after careful evaluation for non-specific neck pain and cervical radiculopathy 4.
- Manual therapy: Combinations of exercise and manual therapy are suggested before medicine for non-specific neck pain 4.
- Acupuncture: May be effective for non-specific neck pain, but not for cervical radiculopathy 4.
- Traction: May be effective for cervical radiculopathy 4.
Physical Therapy Interventions
- Electrotherapy, kinesiotherapy, and manual massage may be effective in treating neck pain 5.
- A combination of these interventions may be more effective than a single intervention 5.
Epidural Injections
- Cervical epidural injections with local anesthetics and steroids may be effective in managing chronic neck and upper extremity pain 6.
- The evidence for epidural injections is good for radiculitis secondary to disc herniation, but fair for axial or discogenic pain, central spinal stenosis, and post-surgery syndrome 6.