Management of Neck Pain in a 15-Year-Old
For a 15-year-old with neck pain, begin with conservative management using NSAIDs (ibuprofen 400 mg every 4-6 hours) and exercise therapy, reserving imaging only for red flag symptoms. 1, 2, 3
Initial Assessment: Screen for Red Flags
The medical history is the most critical step in determining whether imaging or specialist referral is needed. 4 Specifically evaluate for:
- Constitutional symptoms: Fever, unexplained weight loss, night sweats 1, 5
- Neurological deficits: Weakness, numbness, tingling in arms, gait disturbances, bowel/bladder dysfunction 1, 2
- Trauma history: Recent injury or fall 2
- Inflammatory markers: If labs obtained, elevated ESR or CRP warrant further investigation 5
- Infection signs: Swollen lymph nodes, pain with swallowing, immunocompromised state 1, 5
- Vascular concerns: Severe headache, dizziness, visual changes 2
Management Without Red Flags
If no red flags are present, imaging is not indicated and conservative treatment should be initiated. 1, 2
First-Line Treatment
- NSAIDs: Ibuprofen 400 mg every 4-6 hours as needed (maximum 3200 mg daily, though doses above 400 mg show no additional benefit for pain relief) 6, 7
- Exercise therapy: This has the strongest evidence for neck pain treatment and should be started early 3, 7
- Activity modification: Avoid prolonged static postures, encourage proper ergonomics 8
- Reassurance: Most acute neck pain resolves spontaneously within days to weeks 3, 4
Additional Conservative Options
- Muscle relaxants: Consider for acute neck pain with muscle spasm 3, 7
- Physical therapy referral: If pain persists beyond 2-4 weeks 2
- Complementary therapies: Massage, acupuncture, or yoga have weaker supporting evidence but may be considered 7
Management With Red Flags Present
If red flags are identified, obtain MRI of the cervical spine without contrast as the preferred imaging modality. 1, 5, 2
Imaging Selection
- MRI without contrast: Superior for evaluating soft tissue abnormalities, infection, inflammatory processes, disc herniation, and nerve root compression 1, 5
- Plain radiographs: May be considered first if concern is primarily for structural/bony abnormalities or to assess alignment 1, 2
- CT scanning: Not recommended as first-line imaging for neck pain in the absence of trauma 1
Important Caveat About MRI
MRI has a high rate of abnormal findings in asymptomatic individuals—53.9% of people show disc degenerative changes that increase with age but correlate poorly with symptoms. 1, 3 Therefore, MRI findings must always be interpreted in conjunction with clinical symptoms, never in isolation. 1
Follow-Up Strategy
- Reassess at 2-4 weeks if symptoms persist despite conservative management 2
- Consider physical therapy referral if pain continues beyond initial treatment period 2
- Repeat inflammatory markers (if initially elevated) in 2-4 weeks to monitor response 5
- Refer to specialist if MRI reveals significant pathology requiring intervention 5
Key Pitfalls to Avoid
- Do not order imaging without red flags: This rarely changes management and exposes patients to unnecessary findings that may lead to inappropriate interventions 1, 2
- Do not rely on physical examination alone: Physical tests have limited accuracy for diagnosing cervical radiculopathy compared to imaging 1
- Avoid interventional procedures: Strong evidence recommends against epidural injections, facet joint injections, and radiofrequency ablation for chronic spine pain, as they lack proven benefit 1
- Do not assume imaging abnormalities explain symptoms: Degenerative changes are extremely common in asymptomatic adolescents and adults 1, 3
Prognosis
Most acute neck pain episodes resolve with or without treatment, though approximately 30-50% of patients may experience some degree of ongoing pain or recurrences. 1, 3 In this age group, daytime sleepiness and psychological symptoms are associated with increased neck pain prevalence and should be addressed if present. 9