What is the initial evaluation and treatment approach for a patient presenting with acute neck pain?

History Taking and Physical Examination for Acute Neck Pain

Initial Clinical Assessment

A detailed clinical history and physical examination is frequently all that is needed for assessment of acute neck pain, with imaging reserved only for patients with "red flag" symptoms. 1

Critical History Elements

The history should systematically evaluate for "red flag" symptoms that indicate serious underlying pathology requiring immediate investigation 1:

• Risk factors for fracture: History of trauma, osteoporosis, prolonged corticosteroid use 1
• Malignancy indicators: History of cancer, unexplained weight loss, age >50 years 1
• Constitutional symptoms: Fever, night sweats, unintentional weight loss 1
• Infection risk factors: Immunosuppression, IV drug use, recent spinal procedures 1
• Inflammatory conditions: History of ankylosing spondylitis, rheumatoid arthritis, diffuse idiopathic skeletal hyperostosis 1
• Vascular concerns: Age >50 years with concomitant vascular disease, symptoms suggesting vertebral artery dissection 1
• Neurological deficits: Weakness in arms or legs, balance difficulty, bowel/bladder dysfunction, gait disturbance 1
• Coagulopathy: Anticoagulation therapy, bleeding disorders 1

Pain Characterization

Document specific pain characteristics to distinguish mechanical from neuropathic or systemic causes 2, 3:

• Duration: Acute neck pain is defined as <6 weeks duration, with approximately 50% of patients experiencing residual symptoms at 1-year follow-up 1, 3
• Location: Localized neck pain versus radiating pain to shoulders, arms, or between shoulder blades 2
• Quality: Sharp, dull, burning (suggests neuropathic component), or aching 3, 4
• Aggravating factors: Worse with movement, specific positions, or activities like running/lifting 5
• Relieving factors: Rest, position changes, medications 5
• Timing: Constant versus intermittent, worse at certain times of day 3

Prognostic Factors

Identify factors associated with poor prognosis and persistent symptoms 1:

• Female gender 1
• Older age 1
• Severity of pain at presentation 1
• Prior history of neck pain 1
• Previous neck trauma 1
• Coexisting psychosocial pathology including stress and depression 1, 2
• Presence of radicular symptoms 1

Physical Examination Components

Inspection and Palpation

• Visual inspection: Assess for visible deformity, asymmetry, muscle atrophy, or abnormal posture 6
• Palpation: Evaluate for tenderness over vertebral bodies (suggests fracture, infection, or malignancy), paraspinal muscle spasm, and trigger points 1, 6
• Neck masses: Assess for lymphadenopathy or masses that could indicate malignancy or infection 7, 6

Range of Motion Assessment

• Active range of motion: Flexion, extension, lateral bending, and rotation 6, 5
• Limitation patterns: Note if limited by pain versus mechanical restriction 5
• Muscle guarding: Presence suggests acute myofascial strain 5

Neurological Examination

This is the most critical component to distinguish simple mechanical pain from serious pathology requiring urgent intervention 6, 2:

• Motor examination: Test strength in all upper extremity muscle groups (C5-T1 myotomes) and lower extremities if myelopathy suspected 7, 6
• Sensory examination: Assess light touch and pinprick in dermatomal distribution 6
• Reflexes: Biceps (C5-C6), brachioradialis (C6), triceps (C7), and lower extremity reflexes if myelopathy suspected 7
• Pathological reflexes: Hoffman's sign, Babinski sign (indicate myelopathy) 7
• Gait assessment: Evaluate for ataxia or spastic gait suggesting cord compression 7
• Balance testing: Romberg test, tandem gait if balance difficulty reported 7

Special Tests for Radiculopathy

• Spurling's test: Neck extension with lateral bending and axial compression reproduces radicular symptoms 2
• Upper limb tension tests: Assess for nerve root irritation 2

Critical Pitfalls to Avoid

Cardiovascular Masqueraders

Neck pain can be an atypical presentation of cardiac ischemia, particularly in older adults 8:

• If neck pain is reproducible with exertion (running, lifting) but not with cervical spine movements, consider cardiac etiology 8
• Immediate cardiovascular evaluation is warranted if symptoms occur with exercise and resolve with rest 8

Imaging Interpretation Errors

• Do not order imaging in the absence of red flags: Imaging rarely alters management for uncomplicated acute neck pain and leads to detection of incidental findings 1, 6
• Degenerative findings are common in asymptomatic individuals: MRI shows abnormalities in high percentages of pain-free people, so findings must correlate with clinical presentation 1, 7, 3
• Nearly 50% of patients continue to have symptoms at 1 year despite most acute episodes resolving, so clinical correlation is essential 1, 3

Delayed Recognition of Myelopathy

• Weakness in both arms and legs with balance difficulty strongly suggests cervical myelopathy requiring urgent MRI 7
• Delaying appropriate imaging in patients with neurological deficits can lead to irreversible neurological damage 7

When Imaging Is NOT Indicated

For simple acute neck pain without red flags 1, 6:

• No history of trauma 1
• No constitutional symptoms 1
• No neurological deficits 1
• Normal inflammatory markers if obtained 1
• Pain duration <4-6 weeks 6, 5

In these cases, conservative management with NSAIDs, activity modification, and reassurance is appropriate, with follow-up in 2-4 weeks if symptoms persist 7, 5.