What is the best course of treatment for an elderly male patient with chronic left-sided neck pain and swelling, hypertension (high blood pressure), and no discrete cervical lesion on CT scan?

Treatment Approach for Chronic Left-Sided Neck Pain Without Structural Pathology

For this elderly male patient with 6 months of chronic left-sided neck pain, no discrete cervical lesion on CT, and hypertension, the best treatment course is conservative management with NSAIDs (naproxen or ibuprofen) combined with structured exercise therapy, while avoiding interventional procedures such as injections or radiofrequency ablation, which have strong evidence against their use in chronic non-cancer spine pain. 1

Initial Pharmacologic Management

• Start with NSAIDs as first-line therapy for chronic neck pain, specifically naproxen 250-500mg twice daily or ibuprofen 400-600mg three times daily 2, 3, 4, 5
• NSAIDs (including naproxen and ibuprofen) are effective for neck pain and have established efficacy in musculoskeletal conditions 6, 4
• Critical cardiovascular considerations in this elderly patient with hypertension: NSAIDs can lead to new-onset hypertension or worsening of pre-existing hypertension, and patients taking thiazides or loop diuretics may have impaired response to these therapies 3
• Monitor blood pressure closely during NSAID initiation and throughout treatment, as this patient already has elevated blood pressure requiring medication adjustment 3
• Use the lowest effective dose for the shortest duration possible to minimize cardiovascular and gastrointestinal risks 2, 3
• Elderly patients are at increased risk for GI bleeding and cardiovascular events with NSAIDs, so careful monitoring is essential 3, 2

Exercise Therapy as Primary Non-Pharmacologic Treatment

• Exercise therapy has the strongest evidence among non-pharmacologic treatments for chronic neck pain and should be implemented as a core component of treatment 6, 7
• The single trial of physical therapy that provided only one day of relief suggests inadequate treatment duration or intensity 8
• Structured exercise programs should be continued for at least 6 weeks, not just a single session, as evidence supports sustained exercise therapy over this timeframe 8

Manual Therapy Consideration

• Manual therapy (specific mobilization techniques) has demonstrated superior outcomes compared to continued general practitioner care, with success rates of 68.3% versus 35.9% at 7 weeks 8
• Manual therapy scored consistently better on pain intensity (differences of 0.9-1.5 on 0-10 scale) and physical dysfunction measures 8
• Consider referral for manual therapy given the patient's report that "pressing on the area helps him turn his neck," suggesting mechanical dysfunction that may respond to mobilization 8

Interventional Procedures: Strong Recommendation AGAINST

• The 2025 BMJ guideline issues strong recommendations AGAINST the following interventional procedures for chronic axial spine pain (≥3 months): 1
  • Joint radiofrequency ablation with or without joint targeted injection
  • Epidural injection of local anesthetic, steroids, or their combination
  • Joint-targeted injection of local anesthetic, steroids, or their combination
  • Intramuscular injection of local anesthetic with or without steroids
• These recommendations apply specifically to this patient's presentation of chronic (6 months) non-cancer spine pain without radicular symptoms 1
• The evidence for epidural steroid injections is weak and conflicting even in radiculopathy, and this patient has axial neck pain without radicular features 7

Addressing Sleep Positioning

• The patient's need to "lay his head down flatter on a pillow to avoid hurting at night" suggests cervical positioning issues [@patient presentation]
• Recommend cervical pillow support that maintains neutral cervical alignment, avoiding excessive flexion or extension during sleep [@14@]
• This mechanical adjustment may provide symptomatic relief without medication [@14@]

Hypertension Management Considerations

• Before initiating NSAIDs, optimize blood pressure control with adjustment of current antihypertensive medications as the patient has "varying readings" 3
• NSAIDs can blunt the cardiovascular effects of several therapeutic agents used to treat hypertension, including diuretics, ACE inhibitors, and ARBs 3
• Consider alternative analgesics if blood pressure cannot be adequately controlled, though acetaminophen has weaker evidence for neck pain [@14@]

Muscle Relaxants as Adjunctive Therapy

• Short-term use of muscle relaxants may be considered if muscle spasm is prominent, though evidence is limited to acute neck pain [@12@, 5]
• Given the chronic nature (6 months) and the patient's description of swelling and positional relief, muscle relaxants are less likely to provide sustained benefit [@14@]

Red Flags Already Ruled Out

• CT scan showing no discrete cervical lesion effectively rules out serious structural pathology including fracture, malignancy, and significant degenerative disease requiring immediate intervention [@2@, 1]
• The scalp lipoma is an incidental finding unrelated to neck symptoms [@patient presentation]
• No neurological deficits, radicular symptoms, or myelopathy signs are present 1

Follow-Up and Re-Evaluation Timeline

• Re-evaluate at 4-6 weeks to assess response to conservative management 5, 7
• If symptoms have not improved after 6 weeks of appropriate conservative treatment, consider MRI cervical spine without contrast to evaluate for soft tissue pathology not visible on CT 1
• MRI has high sensitivity for detecting soft tissue abnormalities but also has a high false-positive rate in asymptomatic individuals, so should be reserved for cases where findings would change management 1, 7

Common Pitfalls to Avoid

• Do not pursue interventional procedures (injections, radiofrequency ablation) as the 2025 BMJ guideline provides strong evidence against these for chronic axial spine pain 1
• Do not order MRI immediately in the absence of red flags or neurological symptoms, as degenerative findings are common in asymptomatic elderly individuals and may lead to unnecessary interventions 1
• Do not use NSAIDs long-term without monitoring blood pressure and gastrointestinal symptoms, especially in elderly patients with hypertension 2, 3
• Do not attribute treatment failure to "trying physical therapy once" - adequate exercise therapy requires sustained engagement over 6+ weeks 8

Prognosis

• Nearly 50% of individuals with neck pain continue to experience some degree of pain or frequent occurrences beyond the acute phase 7
• Most chronic neck pain cannot be attributed to a specific cause, and approximately 85% of patients present with non-specific pain 1
• Conservative treatment with exercise and appropriate analgesia remains the evidence-based approach even when symptoms persist 1, 6, 7