What are the causes of right-sided neck pain?

Causes of Right-Sided Neck Pain

Right-sided neck pain most commonly results from mechanical causes involving the cervical spine and supporting structures (facet joints, intervertebral discs, muscles, fascia), but serious etiologies including tumor, infection, inflammation, autoimmune disease, and vascular pathology must be systematically excluded through clinical assessment for "red flags." 1

Primary Mechanical Causes (Most Common)

The majority of nontraumatic cervical neck pain originates from mechanical sources:

• Cervical radiculopathy represents the primary consideration for mechanical neuropathic pain, typically from herniated disc or osteophyte compressing nerve roots 1
• Facet joint arthropathy causes localized mechanical pain that may be unilateral 1
• Cervical muscle strain or sprain accounts for most acute presentations in primary care 2, 3
• Myofascial pain dysfunction syndrome produces regional pain patterns that can be lateralized 3
• Cervical osteoarthritis causes degenerative changes, though these correlate poorly with symptoms in isolation 4
• Intervertebral disc degeneration is common but often asymptomatic 4, 5

Serious Etiologies Requiring Urgent Evaluation

When "red flags" are present, alternative diagnoses must be considered:

Vascular Causes

• Carotid artery dissection presents with throbbing neck and face pain with carotid tenderness (carotidynia), requiring urgent vascular imaging to prevent catastrophic complications 6
• Giant cell arteritis causes vascular neck pain in patients >50 years with elevated inflammatory markers 6
• Spontaneous carotid aneurysm manifests as carotidynia with pulsatile neck pain 6

Infectious/Inflammatory Causes

• Vertebral osteomyelitis or discitis presents with constitutional symptoms, elevated inflammatory markers (ESR, CRP, WBC), and history of IV drug use or immunosuppression 1, 4
• Epidural abscess requires emergency evaluation when infection is suspected with neurological symptoms 3
• Inflammatory arthritis (rheumatoid arthritis, ankylosing spondylitis) causes persistent pain with elevated inflammatory markers 1

Malignancy

• Metastatic disease to cervical vertebrae presents with intractable pain, constitutional symptoms (fever, weight loss), and vertebral body tenderness 1
• Primary spinal tumors cause progressive symptoms refractory to conservative treatment 1
• Epidural tumor may cause spinal cord compression requiring urgent intervention 3

Neurological Causes

• Cervical myelopathy from spinal cord compression requires differentiation from radiculopathy through careful neurological examination 1
• Cervical dystonia causes painful dystonic spasms, particularly post-radiation or post-surgical 7
• Hemifacial spasm from facial nerve compression can involve anterior neck musculature 7

Critical "Red Flags" Requiring Immediate Investigation

The following warrant urgent imaging (MRI cervical spine without contrast is preferred) 1, 4:

• Constitutional symptoms: fever, unexplained weight loss, night sweats 1
• Elevated inflammatory markers: ESR, CRP, WBC count 1, 4
• History of malignancy or risk factors for metastatic disease 1
• Immunosuppression or IV drug use increasing infection risk 1
• Neurological deficits: weakness, sensory changes, gait disturbance 1
• Intractable pain despite appropriate conservative therapy 1, 4
• Vertebral body tenderness on palpation 1
• Recent lymphadenopathy with dysphagia suggesting inflammatory/infectious process 4, 7
• Coagulopathy or anticoagulation therapy 1
• Prior neck surgery or radiation predisposing to complications 7

Diagnostic Approach Algorithm

Step 1: Classify Pain Duration and Character

• Acute (<6 weeks): Most resolve spontaneously; imaging usually not indicated without red flags 1
• Chronic (>12 weeks): Nearly 50% develop persistent symptoms requiring comprehensive evaluation 1, 8, 5
• Neuropathic vs. nonneuropathic: Nearly half of chronic neck pain has mixed or predominantly neuropathic features 1, 8

Step 2: Screen for Red Flags

• Perform focused history for constitutional symptoms, trauma history, malignancy risk, infection risk, inflammatory conditions 1
• Examine for vertebral tenderness, neurological deficits, lymphadenopathy 1, 4
• Obtain inflammatory markers (ESR, CRP, WBC) when clinical suspicion exists 1, 4

Step 3: Imaging Decision

• No red flags + acute pain: Imaging usually not appropriate; trial conservative management 1
• Red flags present: MRI cervical spine without contrast is the appropriate next step for evaluating soft tissue abnormalities, inflammatory processes, infection, tumor, or vascular pathology 4, 7
• Focal neurological symptoms: MRI indicated regardless of pain duration 5

Step 4: Consider Referred Pain

• Cardiac or mediastinal pathology can refer to neck, particularly left-sided but occasionally right-sided 3
• Thoracic outlet syndrome may present as neck and upper extremity symptoms 2

Common Pitfalls to Avoid

• Over-reliance on degenerative imaging findings: MRI demonstrates high prevalence of abnormalities in asymptomatic individuals; clinical correlation is essential 4, 5
• Missing vascular emergencies: Carotidynia (throbbing pain with carotid tenderness) requires urgent vascular evaluation, not dismissal as "benign" 6
• Delayed recognition of infection: Elevated CRP with minimal response to NSAIDs warrants MRI before assuming mechanical etiology 4
• Assuming unilateral pain is always mechanical: Serious pathology can present with lateralized symptoms 1