What is the differential diagnosis for acute left-sided neck pain after self-neck manipulation in a healthy 30-year-old female?

Differential Diagnosis for Acute Left-Sided Neck Pain After Self-Neck Manipulation

The most critical diagnosis to exclude immediately in this 30-year-old female is vertebral artery dissection, which can present 12-24 hours after neck hyperextension or rotation and may cause devastating neurologic complications including stroke. 1

Life-Threatening Diagnoses Requiring Urgent Evaluation

Vertebral Artery Dissection (VAD)

• This is the highest priority diagnosis given the mechanism of self-manipulation involving hyperextension/rotation of the cervical spine 1
• VAD can present with isolated unilateral neck pain without neurologic symptoms initially, but cerebral or retinal ischemia develops in 50-95% of cases after warning symptoms 1
• The typical presentation includes sudden, severe pain on one side of the head or neck, which may be accompanied by Horner syndrome (ptosis, miosis, anhidrosis) 1
• Minor trauma such as neck manipulation, hyperflexion, or hyperextension has been directly associated with carotid and vertebral artery dissection 1
• Patients may present with headache, neck pain, vertigo, nausea, visual disturbances, or syncope 1
• Critical pitfall: VAD can present with isolated neck pain as the sole complaint, and neurological examination may be completely unremarkable initially 2

Carotid Artery Dissection

• Self-manipulation can also cause carotid dissection through similar mechanisms of hyperflexion/hyperextension 1
• Presents with unilateral head or neck pain, often with Horner syndrome 1
• Cerebral or retinal ischemia develops in 50-95% of cases following warning symptoms 1

Atlanto-axial Subluxation

• Can occur in previously normal individuals from minor trauma or manipulation 1, 3
• Presents with torticollis or acute neck pain 1, 3
• Requires immediate imaging if suspected 1, 3

Serious Diagnoses Requiring Prompt Evaluation

Cervical Ligamentous Injury

• Self-manipulation can cause ligamentous disruption without obvious fracture 1
• May present with persistent pain and potential delayed instability 1
• Flexion-extension radiographs may be inadequate in the acute setting due to muscle spasm 1

Retropharyngeal Abscess

• Can present with unilateral neck pain without obvious infectious symptoms initially 4
• May have subtle findings on examination but can rapidly deteriorate 4
• Requires high index of suspicion in patients with neck pain and difficulty swallowing 4

Common Mechanical Diagnoses

Facet Joint Injury/Arthropathy

• Mechanical pain from facet joints is the most common cause of nontraumatic neck pain 1
• Presents with localized, often unilateral pain that may radiate to the trapezius region 5
• Pain typically worsens with extension and rotation 1

Muscle Strain/Ligamentous Sprain

• Mechanical pain from muscles or fascia represents the majority of nontraumatic cervical pain 1
• Self-manipulation can cause acute muscle strain 6
• Usually improves with conservative management 1

Cervical Disc Herniation

• Can occur acutely from manipulation 5
• Typically presents with radicular symptoms if nerve root compression occurs 5
• May present with isolated neck pain without radiculopathy 1

Red Flags Assessment Algorithm

Immediate evaluation required if ANY of the following are present: 1, 3

• Neurological deficits (weakness, numbness, altered mental status)
• Severe, sudden-onset headache ("worst headache of life")
• Visual disturbances, vertigo, nausea, or syncope
• Horner syndrome (ptosis, miosis, anhidrosis)
• Fever or constitutional symptoms
• Intractable pain despite therapy
• Vertebral body tenderness on palpation

Diagnostic Approach

If Red Flags Present:

• Immediate emergency department evaluation 3
• CTA or MRA of the neck is the preferred initial vascular imaging to evaluate for arterial dissection 1
• MRI cervical spine without contrast if vascular imaging is negative but suspicion remains high 1, 3
• Do not perform cervical manipulation or physical therapy until vascular injury is excluded 2

If No Red Flags But Concerning History:

• Same-day physician evaluation with detailed neurologic examination 3
• Consider MRI cervical spine without contrast if examination reveals abnormalities or clinical suspicion remains high 1, 3
• Do not assume benign musculoskeletal etiology based solely on age and health status 3, 2

If Benign Examination and Low Suspicion:

• Conservative management with NSAIDs and activity modification 1
• Close observation for development of red flags 3
• Immediate return if: fever develops, neurologic symptoms appear, severe headache with photophobia, or visual disturbances occur 3

Critical Clinical Pitfalls to Avoid

• Never perform cervical manipulation or physical therapy on a patient with acute neck pain following self-manipulation until vascular injury is excluded 2
• Do not rely on normal neurological examination to exclude vertebral artery dissection, as it can present with isolated neck pain 2
• Do not assume young, healthy patients cannot have serious pathology - VAD accounts for 10-15% of ischemic strokes in younger patients 1
• Do not delay vascular imaging if any concerning features are present, as the window for intervention may be narrow 1
• Plain radiographs are inadequate for excluding serious pathology in this clinical scenario 1