What are the treatment options for cervical pain?

Treatment of Cervical Pain

For non-radicular cervical pain without red flags, start with NSAIDs (naproxen 500-550 mg or ibuprofen) combined with physical therapy and exercise, reserving imaging and interventional treatments for cases with red flags, neurological symptoms, or failure of conservative management at 6-12 weeks. 1, 2

Initial Assessment: Identify Red Flags

Before initiating treatment, screen for serious pathology requiring urgent evaluation 1, 3:

• Constitutional symptoms: fever, unexplained weight loss, night sweats 3
• Elevated inflammatory markers: CRP elevation warrants MRI evaluation 3
• Neurological deficits: weakness, sensory loss, myelopathic signs 1
• Recent swollen lymph nodes or dysphagia: suggests inflammatory/infectious process 3
• Severe, intractable pain: unresponsive to initial analgesics 3
• History of malignancy or infection risk factors 1

If red flags are present, obtain MRI cervical spine without contrast immediately before proceeding with conservative treatment. 1, 3

Conservative Treatment (First-Line for 6-12 Weeks)

Pharmacologic Management

NSAIDs are the primary analgesic option, though evidence specifically for cervical pain is limited 4, 2:

• Naproxen 500-550 mg taken 1-2 hours before activities or twice daily 1
• Ibuprofen standard dosing, though peak levels occur 1-2 hours after administration 1
• Note: Evidence for NSAIDs in cervical radicular pain is scant, but they remain first-line based on clinical practice 4

Neuropathic pain medications may be considered if radicular component suspected 4, 5:

• Gabapentin or pregabalin (evidence is scant but commonly used) 4
• Tricyclic antidepressants like nortriptyline 5
• Caution: Limited evidence supports these specifically for cervical radicular pain 4

Muscle relaxants may help acute neck pain with muscle spasm 2

Non-Pharmacologic Management

Exercise therapy is beneficial and should be initiated early 2:

• Physical therapy with or without other treatments 4, 2
• Avoid cervical collars - they provide no benefit and may cause complications 6

Manipulation and mobilization are frequently applied despite limited evidence 7

Natural History and Expectations

Most acute cervical pain resolves spontaneously within 7-8 weeks, but approximately 30-50% of patients develop chronic symptoms lasting beyond one year 1, 6, 2. For cervical radiculopathy specifically, 75-90% achieve symptomatic relief with conservative therapy alone 1.

When to Image

Imaging is NOT indicated initially for mechanical neck pain without red flags 1:

• Radiographs may be obtained first to screen for spondylosis, degenerative disc disease, and malalignment, but degenerative changes are present in 54% of asymptomatic individuals and correlate poorly with symptoms 1
• MRI without contrast is indicated for: red flag symptoms, radiculopathy with neurological deficits, pain refractory to 6-12 weeks of conservative treatment, or before considering interventional procedures 1, 4
• CT is not first-line but may complement MRI for evaluating osseous structures like osteophytes in radiculopathy 1

Critical pitfall: MRI findings frequently overestimate injury severity and show abnormalities in asymptomatic patients - always correlate imaging with clinical findings 1, 6

Cervical Radiculopathy: Specific Considerations

Diagnosis

Cervical radiculopathy presents as unilateral arm pain with or without sensory/motor deficits 1, 4:

• Spurling test and shoulder abduction test are most useful physical examination maneuvers 4
• Diagnosis requires combination of history, examination, and imaging - no single test is definitive 1, 4

Treatment Algorithm

For acute/subacute radiculopathy (<4 months) 4, 5, 8:

1. Conservative treatment first: NSAIDs, neuropathic pain medications (gabapentin/pregabalin, nortriptyline), and physical therapy for 4-6 weeks 4, 5

2. If inadequate response, consider interlaminar cervical epidural steroid injections (ESI) - these show benefit for acute/subacute radicular pain (up to 3 injections over 6 months) 4, 5, 8

   • Avoid transforaminal cervical ESI due to serious adverse events including stroke and death 8
   • Combination therapy (ESI + medications + physical therapy) provided better 3-month outcomes (56.9% positive response) versus conservative treatment alone (26.8%) or ESI alone (36.7%) 5

For chronic radiculopathy (>4 months) 4, 8:

• Epidural corticosteroid efficacy is limited for chronic symptoms 4, 8
• Pulsed radiofrequency treatment adjacent to the dorsal root ganglion is recommended (Grade 1B+) 4, 8
• If pulsed RF is insufficient, conventional radiofrequency treatment may be considered (Grade 2B+) 8

Cervical Facet Pain

More than 50% of pain clinic patients with neck pain may have facet-related pain 7:

• Presents as unilateral pain without arm radiation, painful/limited rotation and retroflexion 7
• No evidence supports intra-articular corticosteroid injection - should only be done in research context 7
• Radiofrequency treatment of the medial branch may be considered, though evidence is limited to observational studies (Grade 2C+) 7, 2
• Weak positive evidence exists for cervical facet joint radiofrequency denervation 2

Surgical Considerations

For radiculopathy with active nerve root compression on imaging 1:

• Anterior cervical decompression improves pain and sensory function at 3-4 months compared to physical therapy or cervical collar (p<0.05) 1
• Benefits diminish by 12 months - no significant differences between surgical and conservative treatment at 1 year 1
• Surgery provides faster initial relief but equivalent long-term outcomes for most patients 1, 2
• Reserve surgery for: severe neurological deficits, progressive myelopathy, or failure of 6-12 weeks conservative management with significant functional impairment 1

Key Clinical Pitfalls

• Do not rely on imaging alone - degenerative changes and disc herniations are common in asymptomatic individuals 1, 6
• Avoid cervical collars - no benefit and potential complications 6
• Do not perform transforaminal cervical ESI - serious adverse event risk outweighs benefits 8
• Elevated CRP requires investigation - obtain MRI before assuming mechanical pain 3
• Most patients improve with time - avoid premature interventions in first 6-12 weeks unless red flags present 1, 2