What could be causing persistent neck muscle pain, temple pressure, and an off-balance feeling when walking in a young adult?

Persistent Off-Balance Sensation with Neck Pain in a Young Adult

This 6-week presentation of off-balance sensation with neck muscle pain and temple pressure in a 32-year-old male most likely represents cervicogenic dizziness from cervical proprioceptive dysfunction, though the duration and incomplete response to steroids warrants evaluation for red flag conditions before assuming a benign mechanical cause.

Critical Red Flag Assessment

The American College of Radiology emphasizes that certain clinical features mandate immediate investigation rather than conservative management 1:

• Constitutional symptoms (fever, unexplained weight loss, night sweats) 1, 2
• Elevated inflammatory markers (ESR, CRP, WBC) - particularly relevant given partial steroid use 1, 2
• Neurological deficits beyond balance disturbance (weakness, sensory changes, gait abnormalities) 1, 3
• Intractable pain despite appropriate conservative therapy 3
• History of malignancy or immunosuppression 1, 3

If any red flags are present, MRI cervical spine without contrast is the appropriate next step to evaluate for infection, inflammatory processes, tumor, or vascular pathology 1, 2, 3.

Most Likely Diagnosis: Cervicogenic Dizziness

Pathophysiology

The cervical spine contains a highly sophisticated proprioceptive system crucial for postural control and balance 4. In patients with neck pain:

• Cervical proprioceptive impairment occurs through multiple mechanisms including muscle inhibition, structural muscle changes, and excessive mechanoreceptor activation from degenerative discs and facet joints 4
• Suboccipital muscle atrophy with fatty infiltration correlates with both chronic neck pain and balance disturbances 5
• Impaired microcirculation in trapezius muscles from altered neuropeptide activity can perpetuate chronic neck pain 6
• Reduced proprioceptive output from atrophied muscles leads to decreased inhibition of nociceptors, creating a cycle of pain and balance dysfunction 5

Clinical Presentation Matches This Pattern

• Non-rotatory, intermittent dizziness during movement is characteristic of cervicogenic dizziness rather than vestibular pathology 7
• Balance problems without true vertigo align with cervical proprioceptive dysfunction 7, 5
• Temple pressure may represent cervicogenic headache, which overlaps with neck pain presentations 1
• Six-week duration places this in the subacute category where nearly 50% of patients develop persistent or recurrent symptoms 8

Diagnostic Workup

Physical Examination Priorities

Focus on specific findings rather than generic assessment 1:

• Cervical range of motion and pain with movement
• Palpation for vertebral body tenderness (suggests infection or metastatic disease) 3
• Neurological examination to exclude myelopathy or radiculopathy 1
• Cervical joint position error testing to assess proprioceptive function 4
• Standing balance assessment (Romberg, tandem gait) 5

Imaging Decision Algorithm

Without red flags (most likely scenario for this patient):

• No imaging indicated for acute/subacute mechanical neck pain 1, 9
• Conservative management for 2-4 weeks before considering imaging 9

With red flags present:

• MRI cervical spine without contrast is the preferred modality for soft tissue abnormalities, inflammatory processes, infection, or tumor 1, 2, 3
• Plain radiographs have limited utility and miss significant pathology 1

Management Strategy

Conservative Treatment (First-Line)

Exercise therapy is the most evidence-supported intervention for neck pain 8:

• Cervical proprioceptive retraining specifically targets the underlying sensorimotor dysfunction 4
• Muscle coordination exercises address the proprioceptive impairment causing balance problems 4
• Early mobilization reduces symptoms in acute and subacute neck pain 1

Pharmacologic Considerations

• Muscle relaxants have some evidence for acute neck pain with muscle spasm 8
• NSAIDs for pain control, though incomplete response suggests need for alternative approach 2
• Avoid prolonged steroid use without clear inflammatory indication 8

Follow-Up Timeline

• Re-evaluate at 2-4 weeks if symptoms persist 9
• Consider physical therapy referral if no improvement by 2-4 weeks 9
• Obtain MRI if symptoms are refractory to 6-8 weeks of conservative treatment 8

Critical Pitfalls to Avoid

• Do not assume benign mechanical pain without screening for red flags, especially given 6-week duration and incomplete steroid response 1, 2
• Do not order imaging prematurely in absence of red flags, as this rarely changes management and has high false-positive rates 1, 9
• Do not overlook cervical proprioceptive dysfunction as the cause of balance problems - this is a specific, treatable entity requiring targeted rehabilitation 4, 5
• Do not attribute all symptoms to anxiety or psychosomatic causes - 72% of patients post-cervical surgery experience persistent dizziness/balance problems with objective findings 7