What is the initial management for a patient presenting with cervicalgia and no other concerns?

Initial Management of Cervicalgia Without Red Flags

For a patient presenting with isolated cervicalgia and no concerning features, imaging is not indicated and conservative management with reassurance should be initiated immediately. 1

Assessment for Red Flag Symptoms

Before proceeding with conservative management, you must explicitly rule out red flags that would change your approach:

• Neurological deficits (weakness, numbness, radiculopathy) 1
• Myelopathy signs (gait disturbance, bowel/bladder dysfunction, hyperreflexia) 2
• Constitutional symptoms (fever, unexplained weight loss) 3
• Trauma history requiring cervical spine injury evaluation 1
• Progressive symptoms despite conservative care 4

If any red flags are present, proceed directly to imaging (MRI without contrast is most sensitive for soft tissue pathology). 1 If absent, as in this case, no imaging is warranted initially. 1

Conservative Management Protocol

First-Line Treatment (Weeks 0-4)

• NSAIDs and muscle relaxants provide effective pain control in the acute phase 5
• Physical therapy with active exercises should begin immediately, not delayed 5
  • Active exercise programs demonstrate superior long-term outcomes compared to medication alone 5
  • Include posture training, cervical stabilization, and stretching 6
• Patient education and reassurance that 88% of cervical radiculopathy cases improve within 4 weeks, and simple cervicalgia has even better prognosis 4

Duration of Conservative Management

• Natural history studies show most patients improve within 4 weeks of symptom onset 4
• Continue conservative management for 4-8 weeks before considering advanced imaging or specialist referral 4
• If symptoms persist beyond 8 weeks, obtain MRI cervical spine without contrast to evaluate for structural pathology requiring intervention 1, 4

Common Pitfalls to Avoid

• Do not order routine imaging in the absence of red flags - radiographs and MRI show high rates of abnormalities in asymptomatic patients that do not correlate with symptoms and lead to unnecessary interventions 1, 3
• Do not delay physical therapy - exercise treatment has superior long-term outcomes when started early rather than relying on medication alone 5
• Do not assume bony prominences on exam are pathologic - prominent cervical vertebrae are normal anatomical variants frequently mistaken for masses 3

When to Escalate Care

Refer for imaging or specialist evaluation if:

• Symptoms persist beyond 4-8 weeks despite appropriate conservative management 4
• New neurological symptoms develop at any point 1, 2
• Pain significantly worsens or changes character 4