What are the recommended management strategies for neck pain?

Management of Neck Pain in the Emergency Department

The recommended first-line approach for neck pain management in the ED is conservative care with education, self-management advice, and exercise, avoiding routine imaging unless specific red flags are present. 1

Initial Assessment and Red Flags

• Perform focused history to identify potential red flags including constitutional symptoms (fever), immunosuppression, progressive neurological deficits, and recent infection 2
• Physical examination should assess range of motion and neurological function (motor strength, sensory changes, reflexes) 2
• Red flags requiring immediate attention include:
  • Progressive neurological deficits 2
  • Recent history of infection with elevated inflammatory markers 2, 3
  • Immunosuppression 2
  • Suspected malignancy or inflammatory arthropathy 1

Imaging Recommendations

• For uncomplicated neck pain without red flags, imaging is not initially recommended as degenerative findings correlate poorly with symptoms 2, 1
• For neck pain with red flags or neurological symptoms, MRI cervical spine without contrast is the preferred imaging modality 2, 1
• For suspected cervical radiculopathy, MRI without contrast is the imaging study of choice 2
• Avoid routine radiological imaging unless serious pathology is suspected or findings would change management 1

First-Line Management

• Provide education about the condition and reassurance about good prognosis 1
• Encourage remaining active and continuing normal activities within pain limits 1
• Recommend exercise as a core component of treatment 1, 4
• Consider NSAIDs for pain control in acute neck pain 2, 4
• Muscle relaxants may be beneficial for acute neck pain associated with muscle spasm 4

Second-Line Interventions

• Manual therapy should only be applied in conjunction with other treatments, not as a stand-alone intervention 1
• Physical therapy with focus on strengthening and posture correction for persistent neck pain 2, 5
• Consider referral for psychological therapies for patients with significant psychosocial factors 1

Interventions to Avoid

• Do not routinely offer opioids for neck pain management 1
• Avoid epidural injections of local anesthetic, steroids, or their combination for chronic neck pain 1
• Avoid joint-targeted injections of local anesthetic, steroids, or their combination for chronic neck pain 1
• Do not perform radiofrequency ablation procedures for chronic neck pain except in specific circumstances 1

Follow-up Recommendations

• If symptoms persist beyond 4-6 weeks despite conservative management, reassess for missed red flags and consider imaging if not previously obtained 2
• For persistent symptoms, consider referral to specialist care for further evaluation 2, 3
• Most acute episodes resolve spontaneously or with conservative treatment, but approximately one-third of patients may experience persistent or recurrent symptoms 6, 4

Special Considerations

• Nearly half of people with chronic neck pain have mixed neuropathic-nociceptive symptoms or predominantly neuropathic symptoms, which may require different management approaches 6
• For patients with cervical radiculopathy, conservative management is the recommended first-line approach 2, 7
• Surgery should only be considered after failed conservative management and is more effective than conservative treatment in the short term but not in the long term 6, 4