What is the best course of treatment for an adult with no significant medical history experiencing upper back pain consistent with muscle spasm near the neck?

Treatment of Upper Back Pain with Muscle Spasm Near Neck

Start with nonpharmacologic therapy—specifically exercise, physical therapy, or spinal manipulation—and avoid imaging unless red flags are present. 1

Initial Management Approach

Conservative therapy is first-line treatment and should be initiated immediately without imaging. 2 Acute uncomplicated thoracic and cervical spine pain is self-limiting in most patients and responds well to medical management and physical therapy. 2 Routine imaging provides no clinical benefit in patients without red flags and frequently shows abnormalities in asymptomatic individuals that do not correlate with symptoms. 1

Nonpharmacologic Interventions (First-Line)

• Exercise therapy provides moderate pain relief and should include supervised stretching and strengthening programs. 1 This has moderate strength of evidence for effectiveness. 1

• Spinal manipulation of the upper back helps lessen neck pain and improve neck motion. 1, 3 Thrust manipulation of the thoracic spine is effective even when patients are uncomfortable with cervical manipulation. 3

• Physical therapy focusing on posture correction and ergonomic modifications is essential. 1 This addresses the gradual stresses from sitting, standing, work postures, and sleeping positions that cause most neck and upper back pain. 3

Pharmacologic Therapy (Adjunctive)

• NSAIDs are the most effective pharmacologic option with moderate-quality evidence. 1 These should be used as adjuncts to physical interventions, not as monotherapy. 1

• Skeletal muscle relaxants (cyclobenzaprine) may be added for short-term use (1-2 weeks maximum) if severe pain with muscle spasm persists. 1, 4 Cyclobenzaprine is FDA-approved as an adjunct to rest and physical therapy for relief of muscle spasm associated with acute, painful musculoskeletal conditions. 4 The typical dose is 5 mg three times daily, which has demonstrated statistically significant superiority over placebo. 4 Do not use muscle relaxants beyond 1-2 weeks, as there is no evidence for longer duration and risks increase. 1

• Duloxetine is second-line therapy only if a neuropathic pain component exists. 1

Red Flags Requiring Urgent Evaluation

Immediate imaging and specialist referral are required if any of the following are present: 2, 1

• Progressive neurological deficits, motor weakness, or sensory changes 1
• Fever (evaluate for vertebral osteomyelitis with blood tests and MRI) 1
• History of recent bloodstream infection, especially Staphylococcus aureus 1
• History of malignancy, IV drug use, or immunosuppression 2, 1
• Unexplained weight loss 2
• Significant trauma 2
• Age >65 years with known osteoporosis or chronic steroid use (risk for compression fracture) 2

Critical Pitfalls to Avoid

• Never prescribe prolonged bed rest—it leads to deconditioning and worse outcomes. 1 This has high strength of evidence. 1

• Do not order routine imaging without red flags. 1 MRI shows high rates of abnormalities in asymptomatic patients, and findings often do not correlate with symptoms. 1

• Do not use muscle relaxants beyond 1-2 weeks. 1 There is no evidence for longer duration and risks increase with prolonged use. 1

• Do not offer interventional procedures (epidural injections, radiofrequency ablation, joint injections) for chronic axial spine pain. 1 These do not improve morbidity, mortality, or quality of life and carry risks. 1

• Do not use systemic corticosteroids—they are no more effective than placebo. 1 This has high strength of evidence. 1

Expected Clinical Course

Most acute neck and upper back pain resolves within 2 months with conservative management. 5 However, nearly 50% of individuals will continue to experience some degree of pain or frequent occurrences. 6 Early initiation of exercise and physical therapy improves outcomes. 1